Provider Demographics
NPI:1548018096
Name:SHEPPARD, KRISTEN NICOLE
Entity type:Individual
Prefix:
First Name:KRISTEN
Middle Name:NICOLE
Last Name:SHEPPARD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:841 HOUSTON AVE
Mailing Address - Street 2:
Mailing Address - City:GRANTS
Mailing Address - State:NM
Mailing Address - Zip Code:87020-3016
Mailing Address - Country:US
Mailing Address - Phone:505-240-7466
Mailing Address - Fax:
Practice Address - Street 1:500 4TH ST NW STE 102
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102-2104
Practice Address - Country:US
Practice Address - Phone:505-356-7650
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-09
Last Update Date:2024-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician