Healthcare Provider Details

I. General information

NPI: 1679297436
Provider Name (Legal Business Name): SHASTA PICKENS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2022
Last Update Date: 01/14/2025
Certification Date: 12/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

117 S 11TH AVE
LAUREL MS
39440-4312
US

IV. Provider business mailing address

117 S 11TH AVE
LAUREL MS
39440-4312
US

V. Phone/Fax

Practice location:
  • Phone: 601-425-3033
  • Fax: 601-422-0693
Mailing address:
  • Phone: 601-425-3033
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number907092
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number907223
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: