Basic Information
| Provider Information | |||||||||
| NPI: | 1760518658 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHEPPARD | ||||||||
| FirstName: | KENDRA | ||||||||
| MiddleName: | DIONNE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1395 NW 167TH ST | ||||||||
| Address2: | |||||||||
| City: | MIAMI GARDENS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331695710 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9013005777 | ||||||||
| FaxNumber: | 9014226092 | ||||||||
| Practice Location | |||||||||
| Address1: | 1056 E RAINES RD | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381166337 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9013005777 | ||||||||
| FaxNumber: | 9014226092 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/26/2007 | ||||||||
| LastUpdateDate: | 11/30/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0300X | 28922 | AL | N | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine | 390200000X | 28922 | AL | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207RG0300X | 61176 | TN | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine |
ID Information
| ID | Type | State | Issuer | Description | 08752708 | 05 | MS | MEDICAID | P00894317 | 01 | AL | RAILROAD MEDICARE | OTHER | 114406 | 05 | AL | MEDICAID | 114403 | 05 | AL | MEDICAID | 114416 | 05 | AL | MEDICAID | 051100368 | 01 | AL | BCBS | OTHER | 114409 | 05 | AL | MEDICAID | 130354 | 05 | AL | MEDICAID |