Healthcare Provider Details

I. General information

NPI: 1316875933
Provider Name (Legal Business Name): KENYON SCOTT SHIFLETT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2026
Last Update Date: 05/12/2026
Certification Date: 05/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

199 N BROOKMOORE DR
COLUMBUS MS
39705-2024
US

IV. Provider business mailing address

199 N BROOKMOORE DR
COLUMBUS MS
39705-2024
US

V. Phone/Fax

Practice location:
  • Phone: 662-328-4542
  • Fax: 662-328-4783
Mailing address:
  • Phone: 662-328-4542
  • Fax: 662-328-4783

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number0591
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: