Healthcare Provider Details

I. General information

NPI: 1407912702
Provider Name (Legal Business Name): SHELLIE E CHEATHAM CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SHELLIE JONES CHEATHAM CRNA

II. Dates (important events)

Enumeration Date: 12/29/2006
Last Update Date: 02/10/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2550 FLOWOOD DR SUITE 400
FLOWOOD MS
39232-9303
US

IV. Provider business mailing address

2550 FLOWOOD DR SUITE 400
FLOWOOD MS
39232-9303
US

V. Phone/Fax

Practice location:
  • Phone: 601-933-9521
  • Fax: 601-933-9525
Mailing address:
  • Phone: 601-933-9521
  • Fax: 601-933-9525

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR851029
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: