Provider Demographics
NPI:1396781993
Name:SHEPARD, THERESA ANN (CRNA)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:ANN
Last Name:SHEPARD
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:THERESA
Other - Middle Name:ANN
Other - Last Name:RATINO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:2985 PESCARA DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32246-5556
Mailing Address - Country:US
Mailing Address - Phone:817-733-8363
Mailing Address - Fax:
Practice Address - Street 1:4500 SAN PABLO RD S
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32224-1865
Practice Address - Country:US
Practice Address - Phone:904-953-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2025-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX724516367500000X
FL11008206367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL108114500Medicaid
TX180369408Medicaid
TX8520UJOtherBCBS
TX86137UOtherBLUE CROSS & BLUE SHIELD
TX180369401Medicaid
TXP01446646OtherRR
TX180369401Medicaid