Healthcare Provider Details

I. General information

NPI: 1477489987
Provider Name (Legal Business Name): SHAY WELLNESS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/22/2026
Last Update Date: 06/22/2026
Certification Date: 06/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

730 GOODMAN RD E STE B
SOUTHAVEN MS
38671-9530
US

IV. Provider business mailing address

730 GOODMAN RD E STE B
SOUTHAVEN MS
38671-9530
US

V. Phone/Fax

Practice location:
  • Phone: 662-649-6087
  • Fax: 662-337-6670
Mailing address:
  • Phone: 662-649-6087
  • Fax: 662-337-6670

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: BLANCHE FOSHEE' PETTY
Title or Position: APRN/OWNER
Credential: NP
Phone: 662-649-6087