Provider Demographics
NPI:1790078301
Name:SHEPARD, MARY C
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:C
Last Name:SHEPARD
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 1:4913 PROFESSIONAL CT
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27609-4913
Mailing Address - Country:US
Mailing Address - Phone:252-244-2388
Mailing Address - Fax:
Practice Address - Street 1:4913 PROFESSIONAL CT
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-4913
Practice Address - Country:US
Practice Address - Phone:252-244-2388
Practice Address - Fax:252-244-0088
Is Sole Proprietor?:No
Enumeration Date:2011-05-16
Last Update Date:2011-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCHC32783747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3418073Medicaid
NC6601442Medicaid