Healthcare Provider Details

I. General information

NPI: 1790609394
Provider Name (Legal Business Name): DESTINY SHAY SOUTHERN FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/06/2026
Last Update Date: 08/06/2026
Certification Date: 08/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2984 FLY RD
SANTA FE TN
38482-3111
US

IV. Provider business mailing address

2984 FLY RD
SANTA FE TN
38482-3111
US

V. Phone/Fax

Practice location:
  • Phone: 931-797-5268
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number41825
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: