Healthcare Provider Details

I. General information

NPI: 1962138487
Provider Name (Legal Business Name): SHANNON MURTAGH RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2022
Last Update Date: 03/06/2024
Certification Date: 03/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3800 I-55 NORTH FRONTAGE ROAD SUITE 102
JACKSON MS
39212
US

IV. Provider business mailing address

5959 S SHERWOOD FOREST BLVD
BATON ROUGE LA
70816-6038
US

V. Phone/Fax

Practice location:
  • Phone: 601-200-6872
  • Fax:
Mailing address:
  • Phone: 601-200-6872
  • Fax: 225-765-9196

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1201X
TaxonomyObesity and Weight Management Nutrition Registered Dietitian
License NumberD1641
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: