Healthcare Provider Details

I. General information

NPI: 1780420836
Provider Name (Legal Business Name): MADISON LYNN SHEPPARD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2024
Last Update Date: 10/02/2026
Certification Date: 10/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7108 S KANNER HWY
STUART FL
34997-7462
US

IV. Provider business mailing address

1079 KINGSTON HWY
KINGSTON GA
30145-1905
US

V. Phone/Fax

Practice location:
  • Phone: 855-832-6727
  • Fax:
Mailing address:
  • Phone: 470-439-4651
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number0133005404
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: