Healthcare Provider Details

I. General information

NPI: 1407555345
Provider Name (Legal Business Name): REBECCA ASHLEY SHEPHERD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/28/2023
Last Update Date: 04/03/2026
Certification Date: 04/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3801 S KANNER HWY
STUART FL
34994-4801
US

IV. Provider business mailing address

3801 S KANNER HWY
STUART FL
34994-4801
US

V. Phone/Fax

Practice location:
  • Phone: 772-221-2003
  • Fax: 772-288-5835
Mailing address:
  • Phone: 772-221-2003
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010-15509
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number9117504
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberMA066570
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: