Healthcare Provider Details

I. General information

NPI: 1700721651
Provider Name (Legal Business Name): SHANNA NICOLA WALLS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2026
Last Update Date: 04/20/2026
Certification Date: 04/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 MCCOMB AVE
PORT GIBSON MS
39150-2915
US

IV. Provider business mailing address

103 MCCOMB AVE
PORT GIBSON MS
39150-2915
US

V. Phone/Fax

Practice location:
  • Phone: 601-747-5362
  • Fax: 601-747-5362
Mailing address:
  • Phone: 601-747-5362
  • Fax: 601-747-5362

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: