Healthcare Provider Details

I. General information

NPI: 1255425922
Provider Name (Legal Business Name): SHAWN FORTENBERRY CHURCHILL COY FNP-BC, PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 07/28/2025
Certification Date: 07/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3600 BLUECUTT RD STE 201
COLUMBUS MS
39705-1397
US

IV. Provider business mailing address

3600 BLUECUTT RD STE 201
COLUMBUS MS
39705-1397
US

V. Phone/Fax

Practice location:
  • Phone: 662-329-3973
  • Fax: 662-329-9056
Mailing address:
  • Phone: 601-942-1855
  • Fax: 662-329-9056

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WR0006X
TaxonomyRegistered Nurse First Assistant
License NumberR789934
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number905512
License Number StateMS
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPN0000032347
License Number StateTN
# 4
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAPN0000032347
License Number StateTN
# 5
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number905512
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: