Healthcare Provider Details

I. General information

NPI: 1669485165
Provider Name (Legal Business Name): MARY ALICE SHEPARD M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2006
Last Update Date: 10/13/2025
Certification Date: 10/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2211 E MILL PLAIN BLVD
VANCOUVER WA
98661-4329
US

IV. Provider business mailing address

PO BOX 31001-4114
PASADENA CA
91110-0001
US

V. Phone/Fax

Practice location:
  • Phone: 360-418-6001
  • Fax: 130-418-6008
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD00023639
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License NumberWA MD00023639
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: