MEDICARE: MS. SHENETTA GOLDMAN F.N.P

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	R864623	MS

General Provider Information

NPI Number	:	1538430087
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. SHENETTA GOLDMAN F.N.P

Provider Business Mailing Address
First Line	:	3502 W NORTHSIDE DRIVE
Second Line	:
City	:	JACKSON
State	:	MS
Zip	:	39213-2617
Country	:	US
Telephone Number	:	601-364-5130
Fax Number	:

Provider Business Practice Location Address
First Line	:	3502 W NORTHSIDE DRIVE
Second Line	:
City	:	JACKSON
State	:	MS
Zip	:	39213-3467
Country	:	US
Telephone Number	:	601-364-5130
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/14/2012
Last Update Date	:	08/12/2013

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