Healthcare Provider Details

I. General information

NPI: 1174626162
Provider Name (Legal Business Name): ANNE E. SHIELDS FNP, CS P-MH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/06/2006
Last Update Date: 09/09/2023
Certification Date: 09/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4055 E BLUEBERRY ST
MERIDIAN ID
83642-8261
US

IV. Provider business mailing address

510 E LOOP 281 STE B-232
LONGVIEW TX
75605-5077
US

V. Phone/Fax

Practice location:
  • Phone: 208-775-7418
  • Fax: 208-647-5008
Mailing address:
  • Phone: 903-475-2602
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number238667
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code364SP0808X
TaxonomyPsychiatric/Mental Health Clinical Nurse Specialist
License Number238667
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code364SP0808X
TaxonomyPsychiatric/Mental Health Clinical Nurse Specialist
License Number66573
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: