Healthcare Provider Details

I. General information

NPI: 1447407895
Provider Name (Legal Business Name): SHANNON RIVES N.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/27/2008
Last Update Date: 09/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1040 RIVER OAKS DR SUITE 103
FLOWOOD MS
39232-9530
US

IV. Provider business mailing address

2500 N STATE ST
JACKSON MS
39216-4500
US

V. Phone/Fax

Practice location:
  • Phone: 601-326-2599
  • Fax: 601-933-0852
Mailing address:
  • Phone: 601-984-6565
  • Fax: 601-984-5658

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR820958
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: