Provider Demographics
NPI:1033659958
Name:GAINES, SHALISA
Entity Type:Individual
Prefix:
First Name:SHALISA
Middle Name:
Last Name:GAINES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:608 HIGHWAY 80 E # C
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MS
Mailing Address - Zip Code:39056-5104
Mailing Address - Country:US
Mailing Address - Phone:769-218-0292
Mailing Address - Fax:601-473-2429
Practice Address - Street 1:608 HIGHWAY 80 E # C
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:MS
Practice Address - Zip Code:39056-5104
Practice Address - Country:US
Practice Address - Phone:769-218-0292
Practice Address - Fax:601-473-2429
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-24
Last Update Date:2017-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor