Healthcare Provider Details

I. General information

NPI: 1154354603
Provider Name (Legal Business Name): SHINITA REED DUDLEY MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SHINTA YEWONDE REED M.D.

II. Dates (important events)

Enumeration Date: 07/08/2006
Last Update Date: 04/16/2023
Certification Date: 04/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

507 SPRINGRIDGE RD STE A
CLINTON MS
39056-5628
US

IV. Provider business mailing address

507 SPRINGRIDGE RD STE A
CLINTON MS
39056-5628
US

V. Phone/Fax

Practice location:
  • Phone: 601-708-1414
  • Fax: 601-708-1415
Mailing address:
  • Phone: 601-708-1414
  • Fax: 601-708-1415

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number18239
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: