Healthcare Provider Details

I. General information

NPI: 1609763812
Provider Name (Legal Business Name): KRISTIAN SHIELDS
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/20/2025
Last Update Date: 06/20/2025
Certification Date: 06/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

604 HIGHWAY 80 W SUITE R OFFICE 2
CLINTON MS
39056-4108
US

IV. Provider business mailing address

122 RICHMOND WAY
CANTON MS
39046-6000
US

V. Phone/Fax

Practice location:
  • Phone: 601-473-2106
  • Fax: 601-473-2150
Mailing address:
  • Phone: 769-990-8040
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: