Provider Demographics
NPI:1679883169
Name:SHEPPARD, ROSETTA BROWN
Entity Type:Individual
Prefix:MRS
First Name:ROSETTA
Middle Name:BROWN
Last Name:SHEPPARD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 60425
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32236-0425
Mailing Address - Country:US
Mailing Address - Phone:904-651-7292
Mailing Address - Fax:904-693-2285
Practice Address - Street 1:9726 REDBIRD CREEK DR S
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32221-3296
Practice Address - Country:US
Practice Address - Phone:904-651-7292
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-18
Last Update Date:2010-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
No332BN1400XSuppliersDurable Medical Equipment & Medical SuppliesNursing Facility Supplies
No335E00000XSuppliersProsthetic/Orthotic Supplier