Provider Demographics
NPI:1699158816
Name:SHEPHERD, YVONNE
Entity type:Individual
Prefix:MRS
First Name:YVONNE
Middle Name:
Last Name:SHEPHERD
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:YVONNE
Other - Middle Name:
Other - Last Name:RUSSELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3402 PRESTON ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48207-2446
Mailing Address - Country:US
Mailing Address - Phone:313-244-7177
Mailing Address - Fax:
Practice Address - Street 1:11000 W MCNICHOLS RD
Practice Address - Street 2:STE 320
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48221-2357
Practice Address - Country:US
Practice Address - Phone:313-340-4442
Practice Address - Fax:313-340-4443
Is Sole Proprietor?:No
Enumeration Date:2015-07-07
Last Update Date:2015-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1348886Medicaid
MI291998Medicaid
MI358813Medicaid
MI24957Medicaid