1407912702 NPI number — MRS. SHELLIE E CHEATHAM CRNA

Table of content: MRS. SHELLIE E CHEATHAM CRNA (NPI 1407912702)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407912702 NPI number — MRS. SHELLIE E CHEATHAM CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CHEATHAM
Provider First Name:
SHELLIE
Provider Middle Name:
E
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
CRNA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CHEATHAM
Provider Other First Name:
SHELLIE
Provider Other Middle Name:
JONES
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
CRNA
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1407912702
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/10/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2550 FLOWOOD DR
Provider Second Line Business Mailing Address:
SUITE 400
Provider Business Mailing Address City Name:
FLOWOOD
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39232-9303
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-933-9521
Provider Business Mailing Address Fax Number:
601-933-9525

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2550 FLOWOOD DR
Provider Second Line Business Practice Location Address:
SUITE 400
Provider Business Practice Location Address City Name:
FLOWOOD
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39232-9303
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-933-9521
Provider Business Practice Location Address Fax Number:
601-933-9525
Provider Enumeration Date:
12/29/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 367500000X , with the licence number:  R851029 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 07620769 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




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