Provider Demographics
NPI:1578920328
Name:BOYD, SHANIKA
Entity Type:Individual
Prefix:
First Name:SHANIKA
Middle Name:
Last Name:BOYD
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 1:130 N HIGH ST
Mailing Address - Street 2:
Mailing Address - City:SHUBUTA
Mailing Address - State:MS
Mailing Address - Zip Code:39360-8870
Mailing Address - Country:US
Mailing Address - Phone:601-687-1391
Mailing Address - Fax:601-687-0051
Practice Address - Street 1:130 N HIGH ST
Practice Address - Street 2:
Practice Address - City:SHUBUTA
Practice Address - State:MS
Practice Address - Zip Code:39360-8870
Practice Address - Country:US
Practice Address - Phone:601-687-1391
Practice Address - Fax:601-687-0051
Is Sole Proprietor?:No
Enumeration Date:2016-01-25
Last Update Date:2021-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR878997363LG0600X
MS878997363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health