Provider Demographics
NPI:1265181374
Name:SHEPPEARD, CHARISSA JO
Entity type:Individual
Prefix:
First Name:CHARISSA
Middle Name:JO
Last Name:SHEPPEARD
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 1:2321 RIVIERA ST
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89509-1145
Mailing Address - Country:US
Mailing Address - Phone:775-527-2511
Mailing Address - Fax:
Practice Address - Street 1:4600 KIETZKE LN STE N258
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89502-5000
Practice Address - Country:US
Practice Address - Phone:775-360-6115
Practice Address - Fax:775-391-5988
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-23
Last Update Date:2022-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV8975225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist