Healthcare Provider Details

I. General information

NPI: 1942760210
Provider Name (Legal Business Name): SHANNON CHRISTIAN BURT FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2019
Last Update Date: 07/24/2024
Certification Date: 07/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 SOUTHCREST CIR STE 212
SOUTHAVEN MS
38671-6721
US

IV. Provider business mailing address

PO BOX 1089
HAMMOND LA
70404-1089
US

V. Phone/Fax

Practice location:
  • Phone: 662-245-5270
  • Fax: 662-351-9471
Mailing address:
  • Phone: 985-892-7070
  • Fax: 985-892-7017

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number903161
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: