1477996700 NPI number — SHANIKA F LEE PCMHT

Table of content: SHANIKA F LEE PCMHT (NPI 1477996700)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477996700 NPI number — SHANIKA F LEE PCMHT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LEE
Provider First Name:
SHANIKA
Provider Middle Name:
F
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PCMHT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
KELLY
Provider Other First Name:
SHANIKA
Provider Other Middle Name:
F
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
NCC
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1477996700
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/29/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P.O. BOX 1
Provider Second Line Business Mailing Address:
3550 HIGHWAY, 468 WEST FISCAL SERVICES
Provider Business Mailing Address City Name:
WHITFIELD
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39193-0175
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-351-8000
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3550 HIGHWAY, 468 WEST
Provider Second Line Business Practice Location Address:
FISCAL SERVICES
Provider Business Practice Location Address City Name:
WHITFIELD
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39193-0157
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-351-8000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/17/2013

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: 101YM0800X , with the licence number:  2543 , 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)





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