Provider Demographics
NPI:1932365038
Name:SHEPARDSON, MARY J (LMT)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:J
Last Name:SHEPARDSON
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:61-274 KAM HWY APT F
Mailing Address - Street 2:
Mailing Address - City:HALEIWA
Mailing Address - State:HI
Mailing Address - Zip Code:96712-1300
Mailing Address - Country:US
Mailing Address - Phone:808-778-7977
Mailing Address - Fax:
Practice Address - Street 1:1315 EKAHA AVE
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96816-4317
Practice Address - Country:US
Practice Address - Phone:808-778-7977
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-29
Last Update Date:2008-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI7367174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist