Healthcare Provider Details

I. General information

NPI: 1487508024
Provider Name (Legal Business Name): SUSIE SHANTILA CANNON TRADITIONAL MIDWIFE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/23/2026
Last Update Date: 02/23/2026
Certification Date: 02/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 W MAIN ST
TUPELO MS
38801-3254
US

IV. Provider business mailing address

184 LEWELLEN ST
WEST POINT MS
39773-2138
US

V. Phone/Fax

Practice location:
  • Phone: 504-533-4716
  • Fax:
Mailing address:
  • Phone: 504-533-4716
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175M00000X
TaxonomyLay Midwife
License NumberNA
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: