Healthcare Provider Details

I. General information

NPI: 1881357853
Provider Name (Legal Business Name): ALYSSA CAITLIN SHEPHERD CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/18/2021
Last Update Date: 01/05/2022
Certification Date: 01/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 TECH CENTER DR STE 100
GAHANNA OH
43230-1987
US

IV. Provider business mailing address

701 TECH CENTER DR STE 250
GAHANNA OH
43230-1987
US

V. Phone/Fax

Practice location:
  • Phone: 614-396-2684
  • Fax: 614-396-2480
Mailing address:
  • Phone: 614-396-2684
  • Fax: 614-396-2480

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberLE00038882
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN.CNP.0030253
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: