Provider Demographics
NPI:1760690010
Name:SHEPHERD, KRISTEN AMANDA (APRN)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:AMANDA
Last Name:SHEPHERD
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8862 GAINESWAY DR
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:38138-8201
Mailing Address - Country:US
Mailing Address - Phone:501-519-0564
Mailing Address - Fax:
Practice Address - Street 1:1 W SUNBRIDGE DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-1825
Practice Address - Country:US
Practice Address - Phone:479-443-5575
Practice Address - Fax:479-442-3732
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-18
Last Update Date:2022-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN29392363LP0808X
373H00000X
AR219568363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No373H00000XNursing Service Related ProvidersDay Training/Habilitation Specialist