Healthcare Provider Details

I. General information

NPI: 1104794049
Provider Name (Legal Business Name): DEVARE ELISE SHEPARD APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/23/2025
Last Update Date: 12/19/2025
Certification Date: 12/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

280 HIGHWAY 35 STE 304
RED BANK NJ
07701-5900
US

IV. Provider business mailing address

280 HIGHWAY 35 STE 304
RED BANK NJ
07701-5900
US

V. Phone/Fax

Practice location:
  • Phone: 732-338-8948
  • Fax:
Mailing address:
  • Phone: 732-338-8948
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1811601768
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: