Healthcare Provider Details

I. General information

NPI: 1558020156
Provider Name (Legal Business Name): ROSETTA SHEPPARD RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/10/2021
Last Update Date: 12/10/2021
Certification Date: 12/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2922 E 78TH ST
CHICAGO IL
60649-4802
US

IV. Provider business mailing address

2701 W 68TH ST
CHICAGO IL
60629-1813
US

V. Phone/Fax

Practice location:
  • Phone: 773-814-6826
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WD0400X
TaxonomyDiabetes Educator Registered Nurse
License Number041387193
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: