Provider Demographics
NPI:1922112978
Name:SHEPHERD, LISA L (CNP)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:L
Last Name:SHEPHERD
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CAMARGO
Mailing Address - State:IL
Mailing Address - Zip Code:61919-3312
Mailing Address - Country:US
Mailing Address - Phone:217-832-2602
Mailing Address - Fax:217-832-8358
Practice Address - Street 1:117 W MAIN ST
Practice Address - Street 2:
Practice Address - City:CAMARGO
Practice Address - State:IL
Practice Address - Zip Code:61919-3312
Practice Address - Country:US
Practice Address - Phone:217-832-2602
Practice Address - Fax:217-832-8358
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL$$$$$$$$$001Medicaid
Q74416Medicare UPIN
K34257Medicare PIN