Healthcare Provider Details

I. General information

NPI: 1164995346
Provider Name (Legal Business Name): RACHELLE SHEPARD APRN, AGNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/10/2019
Last Update Date: 06/13/2023
Certification Date: 06/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

752 DEERWOOD CROSSING DR
COLUMBIA SC
29229-8244
US

IV. Provider business mailing address

752 DEERWOOD CROSSING DR
COLUMBIA SC
29229-8244
US

V. Phone/Fax

Practice location:
  • Phone: 803-290-6357
  • Fax:
Mailing address:
  • Phone: 803-290-6357
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number22445
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number22445
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: