Provider Demographics
NPI:1760518658
Name:SHEPPARD, KENDRA DIONNE (MD)
Entity Type:Individual
Prefix:
First Name:KENDRA
Middle Name:DIONNE
Last Name:SHEPPARD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1395 NW 167TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33169-5710
Mailing Address - Country:US
Mailing Address - Phone:901-300-5777
Mailing Address - Fax:901-422-6092
Practice Address - Street 1:1056 E RAINES RD
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38116-6337
Practice Address - Country:US
Practice Address - Phone:901-300-5777
Practice Address - Fax:901-422-6092
Is Sole Proprietor?:No
Enumeration Date:2007-02-26
Last Update Date:2021-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL28922207RG0300X, 390200000X
TN61176207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08752708Medicaid
ALP00894317OtherRAILROAD MEDICARE
AL114406Medicaid
AL114403Medicaid
AL114416Medicaid
AL051100368OtherBCBS
AL114409Medicaid
AL130354Medicaid
AL114416Medicaid