Healthcare Provider Details

I. General information

NPI: 1346377959
Provider Name (Legal Business Name): BEVERLY JEAN SHEAD LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/28/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

298 ATKINS ST
SARDIS MS
38666-2428
US

IV. Provider business mailing address

2178 LYLES RD
SENATOBIA MS
38668-6106
US

V. Phone/Fax

Practice location:
  • Phone: 662-487-0423
  • Fax:
Mailing address:
  • Phone: 662-562-5168
  • Fax: 662-562-5168

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberP286648
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: