Healthcare Provider Details

I. General information

NPI: 1316653397
Provider Name (Legal Business Name): ALICE SHACKELFORD FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/24/2023
Last Update Date: 01/24/2023
Certification Date: 01/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

971 LAKELAND DR STE 950
JACKSON MS
39216-4608
US

IV. Provider business mailing address

PO BOX 296
BENTON MS
39039-0296
US

V. Phone/Fax

Practice location:
  • Phone: 601-362-6900
  • Fax: 601-362-6111
Mailing address:
  • Phone: 769-234-8311
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number905551
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: