Healthcare Provider Details

I. General information

NPI: 1275597544
Provider Name (Legal Business Name): CHILDREN'S CLINIC OF TUPELO, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/13/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

458 E PRESIDENT AVE
TUPELO MS
38801-5515
US

IV. Provider business mailing address

458 E PRESIDENT AVE
TUPELO MS
38801-5515
US

V. Phone/Fax

Practice location:
  • Phone: 662-842-6088
  • Fax: 662-842-3229
Mailing address:
  • Phone: 662-842-6088
  • Fax: 662-842-3229

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. MARY ANN SHEFFIELD
Title or Position: OWNER/DOCTOR
Credential:
Phone: 662-842-6088