Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 208000000X | Pediatrician | 2003020146 | MO |
Y | 2080P0205X | Pediatric Endocrinologist | 2003020146 | MO |
NPI | 1316112774 |
---|---|
Provider Name | Stacie Shepherd |
First Address | Saint Louis, MO 63105-2161 |
Second Address | Saint Louis, MO 63110-1002 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 28/04/2008 |
Last Update Date | 28/04/2008 |