Healthcare Provider Details

I. General information

NPI: 1871927343
Provider Name (Legal Business Name): SHANNON CREEL WEATHERS FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MRS. SHANNON LEIGH CREEL

II. Dates (important events)

Enumeration Date: 09/02/2013
Last Update Date: 11/26/2021
Certification Date: 11/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 CIRCLE J DR #1
LAUREL MS
39440-1980
US

IV. Provider business mailing address

527 HIGHWAY 533
LAUREL MS
39443-8871
US

V. Phone/Fax

Practice location:
  • Phone: 601-425-0092
  • Fax:
Mailing address:
  • Phone: 601-513-2129
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR880712
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: