Provider Demographics
NPI:1992957195
Name:SHEPHERD, MARY SUSAN (RN-RCS)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:SUSAN
Last Name:SHEPHERD
Suffix:
Gender:F
Credentials:RN-RCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5255 PINE CREST RD
Mailing Address - Street 2:
Mailing Address - City:RHINELANDER
Mailing Address - State:WI
Mailing Address - Zip Code:54501-9231
Mailing Address - Country:US
Mailing Address - Phone:715-362-5081
Mailing Address - Fax:
Practice Address - Street 1:5255 PINE CREST RD
Practice Address - Street 2:
Practice Address - City:RHINELANDER
Practice Address - State:WI
Practice Address - Zip Code:54501-9231
Practice Address - Country:US
Practice Address - Phone:715-362-5081
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-21
Last Update Date:2008-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI164121030163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI35071600Medicaid