Healthcare Provider Details

I. General information

NPI: 1043662398
Provider Name (Legal Business Name): SHANNON VINSON NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2016
Last Update Date: 11/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2670 MCINGVALE RD STE H
HERNANDO MS
38632-8695
US

IV. Provider business mailing address

7271 ALLISON RD
OLIVE BRANCH MS
38654-9203
US

V. Phone/Fax

Practice location:
  • Phone: 662-429-4988
  • Fax: 662-298-2186
Mailing address:
  • Phone: 901-292-4992
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number889627
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number901618
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: