Provider Demographics
NPI:1134184732
Name:SHEPPARD, KIMBERLY A (DC)
Entity type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:A
Last Name:SHEPPARD
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:389 W WEAVER RD
Mailing Address - Street 2:SUITE 2
Mailing Address - City:FORSYTH
Mailing Address - State:IL
Mailing Address - Zip Code:62535-9791
Mailing Address - Country:US
Mailing Address - Phone:217-875-7151
Mailing Address - Fax:217-876-5395
Practice Address - Street 1:389 W WEAVER RD
Practice Address - Street 2:SUITE 2
Practice Address - City:FORSYTH
Practice Address - State:IL
Practice Address - Zip Code:62535-9791
Practice Address - Country:US
Practice Address - Phone:217-875-7151
Practice Address - Fax:217-876-5395
Is Sole Proprietor?:No
Enumeration Date:2006-04-18
Last Update Date:2007-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038009947111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL210215Medicare ID - Type Unspecified
ILU95633Medicare UPIN