MEDICARE: MRS. AMY SHEPPARD CRNA

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	367500000X	Certified Registered Nurse Anesthetist	637921	TX

General Provider Information

NPI Number	:	1457326233
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. AMY SHEPPARD CRNA

Provider Business Mailing Address
First Line	:	2306 6TH AVE
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76110-2510
Country	:	US
Telephone Number	:	817-924-4748
Fax Number	:

Provider Business Practice Location Address
First Line	:	2306 6TH AVE
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76110-2510
Country	:	US
Telephone Number	:	817-924-4748
Fax Number	:

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

Provider Enumeration Date	:	02/23/2006
Last Update Date	:	01/14/2008

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