Healthcare Provider Details

I. General information

NPI: 1316517063
Provider Name (Legal Business Name): SHANNON MARIE HOFFMAN FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SHANNON MARIE WALTERS FNP-BC

II. Dates (important events)

Enumeration Date: 06/25/2021
Last Update Date: 06/25/2021
Certification Date: 06/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3115 AUDUBON DR
LAUREL MS
39440-1913
US

IV. Provider business mailing address

3115 AUDUBON DR
LAUREL MS
39440-1913
US

V. Phone/Fax

Practice location:
  • Phone: 601-531-2200
  • Fax: 601-531-2220
Mailing address:
  • Phone: 601-531-2200
  • Fax: 601-531-2220

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number904424
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: