Healthcare Provider Details

I. General information

NPI: 1760209480
Provider Name (Legal Business Name): SARAH ENSTROM SHORE FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/24/2024
Last Update Date: 10/15/2024
Certification Date: 10/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 MARSHALL ST STE G07
JACKSON MS
39202-1651
US

IV. Provider business mailing address

PO BOX 2153 DEPT 1947
BIRMINGHAM AL
35287-0001
US

V. Phone/Fax

Practice location:
  • Phone: 601-968-3238
  • Fax: 601-968-3237
Mailing address:
  • Phone: 601-292-4562
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number894502
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number906746
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: