Provider Demographics
NPI:1780967521
Name:SHEPARD, STACEY (LAC)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:SHEPARD
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 808
Mailing Address - Street 2:
Mailing Address - City:KAILUA KONA
Mailing Address - State:HI
Mailing Address - Zip Code:96745-0808
Mailing Address - Country:US
Mailing Address - Phone:808-238-4072
Mailing Address - Fax:808-326-1955
Practice Address - Street 1:75-240 NANI KAILUA DR
Practice Address - Street 2:#6A
Practice Address - City:KAILUA KONA
Practice Address - State:HI
Practice Address - Zip Code:96740-2074
Practice Address - Country:US
Practice Address - Phone:808-238-4072
Practice Address - Fax:808-326-1955
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-27
Last Update Date:2011-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIACU1010171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist