Basic Information
| Provider Information | |||||||||
| NPI: | 1114904976 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHEPHERD | ||||||||
| FirstName: | SHANNON | ||||||||
| MiddleName: | ELIZABETH | ||||||||
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| Credential: | CNM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 770 NORTHPOINT PKWY STE 100 | ||||||||
| Address2: | |||||||||
| City: | WEST PALM BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334071901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5616553331 | ||||||||
| FaxNumber: | 5616553744 | ||||||||
| Practice Location | |||||||||
| Address1: | 770 NORTHPOINT PKWY STE 200 | ||||||||
| Address2: | |||||||||
| City: | WEST PALM BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334071901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5616553331 | ||||||||
| FaxNumber: | 5616553744 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/22/2005 | ||||||||
| LastUpdateDate: | 10/07/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367A00000X | APRN9341130 | FL | N | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife | 367A00000X | APRN11010478 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife |
ID Information
| ID | Type | State | Issuer | Description | 765509669A | 05 | GA | MEDICAID |