Healthcare Provider Details

I. General information

NPI: 1720296429
Provider Name (Legal Business Name): FANNIE T SHELTON NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4041 KNIGHT ARNOLD RD
MEMPHIS TN
38118-2128
US

IV. Provider business mailing address

4041 KNIGHT ARNOLD RD
MEMPHIS TN
38118-2128
US

V. Phone/Fax

Practice location:
  • Phone: 901-821-5600
  • Fax: 901-821-5864
Mailing address:
  • Phone: 901-821-5600
  • Fax: 901-821-5864

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAPN0000005078
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: