Provider Demographics
NPI:1912582438
Name:SHEPHERD, MICHELLE DAWN
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:DAWN
Last Name:SHEPHERD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:425 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42001-0713
Mailing Address - Country:US
Mailing Address - Phone:270-442-7121
Mailing Address - Fax:
Practice Address - Street 1:1051 N 16TH ST STE B
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:KY
Practice Address - Zip Code:42071-8511
Practice Address - Country:US
Practice Address - Phone:270-753-6622
Practice Address - Fax:270-753-9669
Is Sole Proprietor?:No
Enumeration Date:2021-03-16
Last Update Date:2021-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1085212163W00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100730860Medicaid