MEDICARE: TIFFANY SANDRA SHEPERD DNP, RN

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	163WP0808X	Psychiatric/Mental Health Registered Nurse	192836	WI
2	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	8112	WI

General Provider Information

NPI Number	:	1548788623
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TIFFANY SANDRA SHEPERD DNP, RN

Provider Business Mailing Address
First Line	:	5334 SIX MILE RD
Second Line	:
City	:	BELGIUM
State	:	WI
Zip	:	53004-9747
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4600 W SCHROEDER DR
Second Line	:
City	:	BROWN DEER
State	:	WI
Zip	:	53223-1469
Country	:	US
Telephone Number	:	414-865-2500
Fax Number	:

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

Provider Enumeration Date	:	09/08/2017
Last Update Date	:	01/03/2018

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