Basic Information
| Provider Information | |||||||||
| NPI: | 1710300660 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHEPHERD | ||||||||
| FirstName: | REBECCA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1325 | ||||||||
| Address2: | |||||||||
| City: | CORBIN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 407021325 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6065268131 | ||||||||
| FaxNumber: | 6065288661 | ||||||||
| Practice Location | |||||||||
| Address1: | 403 SYCAMORE ST | ||||||||
| Address2: | |||||||||
| City: | WILLIAMSBURG | ||||||||
| State: | KY | ||||||||
| PostalCode: | 407691153 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6065498244 | ||||||||
| FaxNumber: | 6065490354 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/29/2014 | ||||||||
| LastUpdateDate: | 12/02/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 12/02/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 3008495 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | P01510190 | 01 | KY | RR MEDICARE | OTHER | 7100363990 | 05 | KY | MEDICAID |