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General NPI Number Information
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NPI Number | 1548645963
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Entity Type | Individual
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Provider Name | AMETHYST SHEPHERD
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Gender | Female
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Dates
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Enumeration Date | 07/27/2015
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Last Update Date | 07/27/2015
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Provider Practice Location Address
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Address Line | 6120 MULLEN RD SE
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City | OLYMPIA
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State | WA
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Zip | 98503-7147
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Country | US
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Telephone | 443-254-1149
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Fax |
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Provider Business Mailing Address
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Address Line | 1060 CENTRAL ST SE
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City | OLYMPIA
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State | WA
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Zip | 98501-1763
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Country | US
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Telephone | 443-254-1149
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | AT-485
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License Number State | ID
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