Healthcare Provider Details

I. General information

NPI: 1659646958
Provider Name (Legal Business Name): DIANE SHEPHERD REGISTERED NURSE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2012
Last Update Date: 03/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 SIXTH ST. NW SUITE E
CASS LAKE MN
56601-3061
US

IV. Provider business mailing address

115 6TH ST. NW SUITE E
CASS LAKE MN
56633-3061
US

V. Phone/Fax

Practice location:
  • Phone: 218-335-8315
  • Fax: 218-335-4578
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License NumberR-158091-4
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code163WM0102X
TaxonomyMaternal Newborn Registered Nurse
License NumberR-158091-4
License Number StateMN
# 3
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License NumberR-158091-4
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: