Healthcare Provider Details

I. General information

NPI: 1043295975
Provider Name (Legal Business Name): JUDY GREENE SHEPHERD CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/14/2005
Last Update Date: 08/17/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

MEDICAL CENTER BLVD
WINSTON SALEM NC
27157-0001
US

IV. Provider business mailing address

559 GREEN SHEPHERD FARM RD
N WILKESBORO NC
28659-8112
US

V. Phone/Fax

Practice location:
  • Phone: 336-713-2555
  • Fax:
Mailing address:
  • Phone: 336-667-1373
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number35670
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: