Provider Demographics
NPI:1871997973
Name:SHEPPARD, MELINDA
Entity type:Individual
Prefix:
First Name:MELINDA
Middle Name:
Last Name:SHEPPARD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MELINDA
Other - Middle Name:MARIE
Other - Last Name:BALLINGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:237 WILLIAM HOWARD TAFT RD
Mailing Address - Street 2:2ND FLOOR, CBO 2-3
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45219-2610
Mailing Address - Country:US
Mailing Address - Phone:513-792-7800
Mailing Address - Fax:513-792-7827
Practice Address - Street 1:11140 MONTGOMERY RD
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45249-2309
Practice Address - Country:US
Practice Address - Phone:513-792-7800
Practice Address - Fax:513-792-7827
Is Sole Proprietor?:No
Enumeration Date:2014-10-17
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH16240363LA2200X, 363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100314950Medicaid
OHH410230Medicare PIN