Healthcare Provider Details

I. General information

NPI: 1407573843
Provider Name (Legal Business Name): IVEY BURT SHELTON FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/26/2022
Last Update Date: 10/26/2022
Certification Date: 10/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

129 VIEWPOINTE DR
CLINTON MS
39056-6085
US

IV. Provider business mailing address

129 VIEWPOINTE DR
CLINTON MS
39056-6085
US

V. Phone/Fax

Practice location:
  • Phone: 601-527-4465
  • Fax:
Mailing address:
  • Phone: 601-527-4465
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number905570
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: