Healthcare Provider Details

I. General information

NPI: 1366851321
Provider Name (Legal Business Name): MRS. SHAWNTA SENICE GANDY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/04/2014
Last Update Date: 10/05/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27 CANDELABRA ST
PETAL MS
39465-9008
US

IV. Provider business mailing address

27 CANDELABRA ST
PETAL MS
39465-9008
US

V. Phone/Fax

Practice location:
  • Phone: 601-620-8011
  • Fax:
Mailing address:
  • Phone: 601-620-8011
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR883735
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR883735
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: