Provider Demographics
NPI:1740750926
Name:SHEPHARD, ANGELA STEPHANIE (LMT)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:STEPHANIE
Last Name:SHEPHARD
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 LYLE LOOP
Mailing Address - Street 2:
Mailing Address - City:SELAH
Mailing Address - State:WA
Mailing Address - Zip Code:98942-8869
Mailing Address - Country:US
Mailing Address - Phone:509-834-8074
Mailing Address - Fax:
Practice Address - Street 1:3910 SUMMITVIEW AVE
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98908
Practice Address - Country:US
Practice Address - Phone:509-834-8074
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-29
Last Update Date:2018-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60892517225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist