Healthcare Provider Details

I. General information

NPI: 1447113006
Provider Name (Legal Business Name): SHAYNA SANDERS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/09/2025
Last Update Date: 12/09/2025
Certification Date: 12/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14065 HARLEY DR
DIBERVILLE MS
39540-5069
US

IV. Provider business mailing address

14065 HARLEY DR
DIBERVILLE MS
39540-5069
US

V. Phone/Fax

Practice location:
  • Phone: 731-412-8340
  • Fax:
Mailing address:
  • Phone: 731-400-2556
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number4056
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: