Healthcare Provider Details

I. General information

NPI: 1396074787
Provider Name (Legal Business Name): SHEENA M FANTON PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/14/2009
Last Update Date: 12/14/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2120 ENTERPRISE DR SUITE A
BILOXI MS
39531-4039
US

IV. Provider business mailing address

PO BOX 8419
BILOXI MS
39535-8087
US

V. Phone/Fax

Practice location:
  • Phone: 228-702-0882
  • Fax: 228-702-0082
Mailing address:
  • Phone: 228-388-5714
  • Fax: 228-388-0017

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT4597
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: