Provider Demographics
NPI:1659646958
Name:SHEPHERD, DIANE (REGISTERED NURSE)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:SHEPHERD
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 6TH ST. NW
Mailing Address - Street 2:SUITE E
Mailing Address - City:CASS LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:56633-3061
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:115 SIXTH ST. NW
Practice Address - Street 2:SUITE E
Practice Address - City:CASS LAKE
Practice Address - State:MN
Practice Address - Zip Code:56601-3061
Practice Address - Country:US
Practice Address - Phone:218-335-8315
Practice Address - Fax:218-335-4578
Is Sole Proprietor?:No
Enumeration Date:2012-03-20
Last Update Date:2012-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR-158091-4163WC1500X, 163WM0102X, 163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC1500XNursing Service ProvidersRegistered NurseCommunity Health
No163WM0102XNursing Service ProvidersRegistered NurseMaternal Newborn
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health