Provider Demographics
NPI:1407912702
Name:CHEATHAM, SHELLIE E (CRNA)
Entity Type:Individual
Prefix:MRS
First Name:SHELLIE
Middle Name:E
Last Name:CHEATHAM
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:MRS
Other - First Name:SHELLIE
Other - Middle Name:JONES
Other - Last Name:CHEATHAM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CRNA
Mailing Address - Street 1:2550 FLOWOOD DR
Mailing Address - Street 2:SUITE 400
Mailing Address - City:FLOWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:39232-9303
Mailing Address - Country:US
Mailing Address - Phone:601-933-9521
Mailing Address - Fax:601-933-9525
Practice Address - Street 1:2550 FLOWOOD DR
Practice Address - Street 2:SUITE 400
Practice Address - City:FLOWOOD
Practice Address - State:MS
Practice Address - Zip Code:39232-9303
Practice Address - Country:US
Practice Address - Phone:601-933-9521
Practice Address - Fax:601-933-9525
Is Sole Proprietor?:No
Enumeration Date:2006-12-29
Last Update Date:2016-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR851029367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS07620769Medicaid
MS471467YPC0Medicare PIN