Provider Demographics
NPI:1154373611
Name:SHEPARD, KELLEY JEAN (OTR/L, CHT)
Entity type:Individual
Prefix:
First Name:KELLEY
Middle Name:JEAN
Last Name:SHEPARD
Suffix:
Gender:F
Credentials:OTR/L, CHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:89 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PLAISTOW
Mailing Address - State:NH
Mailing Address - Zip Code:03865-3010
Mailing Address - Country:US
Mailing Address - Phone:603-382-3031
Mailing Address - Fax:603-382-5580
Practice Address - Street 1:89 MAIN ST
Practice Address - Street 2:
Practice Address - City:PLAISTOW
Practice Address - State:NH
Practice Address - Zip Code:03865-3010
Practice Address - Country:US
Practice Address - Phone:603-382-3031
Practice Address - Fax:603-382-5580
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2015-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH684174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0707724Medicaid
30414644OtherEDS
NH5325560OtherCIGNA HEALTHCARE
MAAA50990OtherHARVARD PILGRIM
MAOT0159OtherBLUE CROSS BLUE SHIELD
NH13Y009078NH01OtherANTHEM
NH5686743OtherFIRST HEALTH AND/OR CCN
655894OtherTUFTS
P00356772OtherRAILROAD MEDICARE
NH13Y009078NH01OtherANTHEM
MAOT0159OtherBLUE CROSS BLUE SHIELD