Basic Information
| Provider Information | |||||||||
| NPI: | 1548532401 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHEPHERD | ||||||||
| FirstName: | MARION | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1988 | ||||||||
| Address2: | |||||||||
| City: | HAZARD | ||||||||
| State: | KY | ||||||||
| PostalCode: | 417021988 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6064357643 | ||||||||
| FaxNumber: | 6064365282 | ||||||||
| Practice Location | |||||||||
| Address1: | 101 TOWN AND COUNTRY LN STE 100 | ||||||||
| Address2: | |||||||||
| City: | HAZARD | ||||||||
| State: | KY | ||||||||
| PostalCode: | 417019524 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6064331300 | ||||||||
| FaxNumber: | 6064391400 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/07/2012 | ||||||||
| LastUpdateDate: | 02/12/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 3007171 | KY | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363L00000X | 3007171 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 7100196890 | 05 | KY | MEDICAID |