Provider Demographics
NPI:1417012956
Name:SHEPHERD, SHERRY LYNNE
Entity type:Individual
Prefix:MRS
First Name:SHERRY
Middle Name:LYNNE
Last Name:SHEPHERD
Suffix:
Gender:F
Credentials:
Other - Prefix:DR
Other - First Name:SHERRY
Other - Middle Name:
Other - Last Name:SHEPHERD
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:27 MONTEBELLO RD
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81001-1236
Mailing Address - Country:US
Mailing Address - Phone:719-545-1530
Mailing Address - Fax:719-545-2899
Practice Address - Street 1:102 SANTA FE AVE
Practice Address - Street 2:
Practice Address - City:LA JUNTA
Practice Address - State:CO
Practice Address - Zip Code:81050-1523
Practice Address - Country:US
Practice Address - Phone:719-384-8719
Practice Address - Fax:719-384-8738
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-26
Last Update Date:2012-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2337152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO73921050Medicaid
COP00476844OtherRAILROAD MEDICARE
COP00476844OtherRAILROAD MEDICARE