Provider Demographics
NPI:1447899158
Name:SHEPHERD, KELLIE MARIE (CARE GIVER)
Entity type:Individual
Prefix:
First Name:KELLIE
Middle Name:MARIE
Last Name:SHEPHERD
Suffix:
Gender:F
Credentials:CARE GIVER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:686 SW LORRAINE DR
Mailing Address - Street 2:
Mailing Address - City:MADRAS
Mailing Address - State:OR
Mailing Address - Zip Code:97741-9333
Mailing Address - Country:US
Mailing Address - Phone:541-325-1654
Mailing Address - Fax:
Practice Address - Street 1:686 SW LORRAINE DR
Practice Address - Street 2:
Practice Address - City:MADRAS
Practice Address - State:OR
Practice Address - Zip Code:97741-9333
Practice Address - Country:US
Practice Address - Phone:541-325-1654
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-27
Last Update Date:2019-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374U00000XNursing Service Related ProvidersHome Health AideGroup - Single Specialty