Provider Demographics
NPI:1710017140
Name:SHEPPARD FRIES, MARY (RN)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:SHEPPARD FRIES
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4300 BARTLETT ST
Mailing Address - Street 2:
Mailing Address - City:HOMER
Mailing Address - State:AK
Mailing Address - Zip Code:99603-7005
Mailing Address - Country:US
Mailing Address - Phone:907-235-0369
Mailing Address - Fax:
Practice Address - Street 1:451 STERLING HWY
Practice Address - Street 2:
Practice Address - City:HOMER
Practice Address - State:AK
Practice Address - Zip Code:99603-7440
Practice Address - Country:US
Practice Address - Phone:907-235-0369
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKHH2711163WH0200X, 374U00000X, 376K00000X
AKCMG799171M00000X
AKHC2563171WH0202X, 372500000X
AKPCG519A3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered163WH0200XNursing Service ProvidersRegistered NurseHome Health
Not Answered171M00000XOther Service ProvidersCase Manager/Care Coordinator
Not Answered171WH0202XOther Service ProvidersContractorHome Modifications
Not Answered372500000XNursing Service Related ProvidersChore Provider
Not Answered3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Not Answered374U00000XNursing Service Related ProvidersHome Health Aide
Not Answered376K00000XNursing Service Related ProvidersNurse's Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKHH2711Medicaid
AKCMG799Medicaid
AKMSO272Medicaid
AKNA3799Medicaid
AKHC2563Medicaid
AKPCG519AMedicaid
AKNA3799Medicaid