Provider Demographics
NPI:1265510440
Name:FREEMAN, SHAUNDA T (FNP)
Entity Type:Individual
Prefix:MRS
First Name:SHAUNDA
Middle Name:T
Last Name:FREEMAN
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 741
Mailing Address - Street 2:
Mailing Address - City:PORT GIBSON
Mailing Address - State:MS
Mailing Address - Zip Code:39150-0741
Mailing Address - Country:US
Mailing Address - Phone:601-437-3050
Mailing Address - Fax:601-437-3051
Practice Address - Street 1:2045 HWY 61 NORTH
Practice Address - Street 2:
Practice Address - City:PORT GIBSON
Practice Address - State:MS
Practice Address - Zip Code:39150-4262
Practice Address - Country:US
Practice Address - Phone:601-437-3050
Practice Address - Fax:601-437-3051
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2011-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR864672363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS02975221Medicaid
Q77527Medicare UPIN
500002519Medicare Oscar/Certification