| NPI | 1225381767 |
|---|---|
| Former Name | SHANDA DAWN SOUTHARD |
| Entity Type | Individual |
| Gender | Female |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: KY 3007749) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: KY 3007749) |
| Enumeration Date | 2012-10-22 |
| Last Update Date | 2016-03-01 |