Healthcare Provider Details

I. General information

NPI: 1376420570
Provider Name (Legal Business Name): SHAWNER TYSON PHLEBOTOMIST
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/19/2025
Last Update Date: 08/19/2025
Certification Date: 08/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

665 S PEAR ORCHARD RD
RIDGELAND MS
39157-4861
US

IV. Provider business mailing address

5537 HIGHWAY 84
PRENTISS MS
39474-4482
US

V. Phone/Fax

Practice location:
  • Phone: 601-921-5081
  • Fax: 601-860-9834
Mailing address:
  • Phone: 601-441-8326
  • Fax: 601-860-9834

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246RP1900X
TaxonomyPhlebotomy Technician
License Number063018-PWECW15312
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: