Provider Demographics
NPI:1447407895
Name:RIVES, SHANNON (NP)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:RIVES
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 N STATE ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4500
Mailing Address - Country:US
Mailing Address - Phone:601-984-6565
Mailing Address - Fax:601-984-5658
Practice Address - Street 1:1040 RIVER OAKS DR
Practice Address - Street 2:SUITE 103
Practice Address - City:FLOWOOD
Practice Address - State:MS
Practice Address - Zip Code:39232-9530
Practice Address - Country:US
Practice Address - Phone:601-326-2599
Practice Address - Fax:601-933-0852
Is Sole Proprietor?:No
Enumeration Date:2008-08-27
Last Update Date:2018-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR820958363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS06286014Medicaid
MS1336216431OtherGROUP NPI
MS06286014Medicaid