Healthcare Provider Details

I. General information

NPI: 1558713420
Provider Name (Legal Business Name): RENEE ELIZABETH SHEPHERD DPM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2016
Last Update Date: 06/05/2025
Certification Date: 06/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14 DOCTORS CIR STE 2
SUPPLY NC
28462-4088
US

IV. Provider business mailing address

14 DOCTORS CIR STE 2
SUPPLY NC
28462-4088
US

V. Phone/Fax

Practice location:
  • Phone: 107-556-5129
  • Fax: 910-755-6548
Mailing address:
  • Phone: 107-556-5129
  • Fax: 910-755-6548

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberE5569
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberSC006766
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number0103301338
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: