Provider Demographics
NPI:1982272779
Name:SHEPARD, WANDA (NURSE ASSISTANT)
Entity type:Individual
Prefix:
First Name:WANDA
Middle Name:
Last Name:SHEPARD
Suffix:
Gender:F
Credentials:NURSE ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8366 SCHAEFER HWY
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48228-2779
Mailing Address - Country:US
Mailing Address - Phone:313-721-5849
Mailing Address - Fax:
Practice Address - Street 1:8366 SCHAEFER HWY
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48228-2779
Practice Address - Country:US
Practice Address - Phone:313-721-5849
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-16
Last Update Date:2021-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI87-0883270251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health