Healthcare Provider Details

I. General information

NPI: 1629333208
Provider Name (Legal Business Name): ALICE LYN SHEPARD PNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2012
Last Update Date: 06/28/2023
Certification Date: 06/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

307 BOATNER RD STE 114
EGLIN AFB FL
32542
US

IV. Provider business mailing address

2501 CAPEHART RD
BELLEVUE NE
68123
US

V. Phone/Fax

Practice location:
  • Phone: 850-883-8550
  • Fax:
Mailing address:
  • Phone: 402-294-6077
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberAP130674
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: