Provider Demographics
NPI:1881017226
Name:SHEPHERD, THERESA
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:SHEPHERD
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 1:5008 BRITTONFIELD PKWY
Mailing Address - Street 2:SUITE 700
Mailing Address - City:EAST SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13057-9248
Mailing Address - Country:US
Mailing Address - Phone:315-472-7504
Mailing Address - Fax:315-479-8639
Practice Address - Street 1:5008 BRITTONFIELD PKWY
Practice Address - Street 2:SUITE 700
Practice Address - City:EAST SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13057
Practice Address - Country:US
Practice Address - Phone:315-472-7504
Practice Address - Fax:315-479-8639
Is Sole Proprietor?:No
Enumeration Date:2014-01-21
Last Update Date:2018-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2537133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist