Provider Demographics
NPI:1558713420
Name:SHEPHERD, RENEE ELIZABETH (DPM)
Entity type:Individual
Prefix:
First Name:RENEE
Middle Name:ELIZABETH
Last Name:SHEPHERD
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 DOCTORS CIR STE 2
Mailing Address - Street 2:
Mailing Address - City:SUPPLY
Mailing Address - State:NC
Mailing Address - Zip Code:28462-4088
Mailing Address - Country:US
Mailing Address - Phone:107-556-5129
Mailing Address - Fax:910-755-6548
Practice Address - Street 1:14 DOCTORS CIR STE 2
Practice Address - Street 2:
Practice Address - City:SUPPLY
Practice Address - State:NC
Practice Address - Zip Code:28462-4088
Practice Address - Country:US
Practice Address - Phone:107-556-5129
Practice Address - Fax:910-755-6548
Is Sole Proprietor?:No
Enumeration Date:2016-07-05
Last Update Date:2025-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE5569213ES0103X
PASC006766390200000X
VA0103301338213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAE5569OtherLICENSE
CAE5569OtherLICENSE