MEDICARE: LISA SHEPARD CRNFA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163WR0006X	Registered Nurse First Assistant	RN046743	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	124186	OTHER		HEALTHNET
2	2224040	OTHER		AETNA

General Provider Information

NPI Number	:	1427134212
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA SHEPARD CRNFA

Provider Business Mailing Address
First Line	:	609 S CLEARVIEW AVE
Second Line	:
City	:	MESA
State	:	AZ
Zip	:	85208-1922
Country	:	US
Telephone Number	:	480-201-6754
Fax Number	:	480-396-5130

Provider Business Practice Location Address
First Line	:	609 S CLEARVIEW AVE
Second Line	:
City	:	MESA
State	:	AZ
Zip	:	85208-1922
Country	:	US
Telephone Number	:	480-201-6754
Fax Number	:	480-396-5130

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/27/2006
Last Update Date	:	01/20/2016

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