Healthcare Provider Details

I. General information

NPI: 1306431135
Provider Name (Legal Business Name): KYLEIGH MCILWAIN SHIRAH FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KYLEIGH ALEXIS ODOM RN

II. Dates (important events)

Enumeration Date: 03/03/2021
Last Update Date: 03/03/2021
Certification Date: 02/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

951 MATTHEW DR STE D
WAYNESBORO MS
39367-2566
US

IV. Provider business mailing address

951 MATTHEW DR STE D
WAYNESBORO MS
39367-2566
US

V. Phone/Fax

Practice location:
  • Phone: 601-671-2795
  • Fax: 601-735-4227
Mailing address:
  • Phone: 601-671-2795
  • Fax: 601-735-4227

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number904502
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: