Provider Demographics
NPI:1598061921
Name:SEALS, SHANNON NICOLE (FNP)
Entity Type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:NICOLE
Last Name:SEALS
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 1:647 JACKSON AVE # A
Mailing Address - Street 2:
Mailing Address - City:OCEAN SPRINGS
Mailing Address - State:MS
Mailing Address - Zip Code:39564-4621
Mailing Address - Country:US
Mailing Address - Phone:228-382-0855
Mailing Address - Fax:601-602-2015
Practice Address - Street 1:647 JACKSON AVE # A
Practice Address - Street 2:
Practice Address - City:OCEAN SPRINGS
Practice Address - State:MS
Practice Address - Zip Code:39564-4621
Practice Address - Country:US
Practice Address - Phone:228-382-0855
Practice Address - Fax:601-602-2015
Is Sole Proprietor?:No
Enumeration Date:2011-02-02
Last Update Date:2024-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSF0311064363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00584811Medicaid