Provider Demographics
NPI:1609226109
Name:LOFTIN, SHANNON HANEY (FNP-C)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:HANEY
Last Name:LOFTIN
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1065 E BROAD ST
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:MS
Mailing Address - Zip Code:39654-7703
Mailing Address - Country:US
Mailing Address - Phone:601-587-4051
Mailing Address - Fax:601-587-0306
Practice Address - Street 1:502 BROAD ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MS
Practice Address - Zip Code:39429-3037
Practice Address - Country:US
Practice Address - Phone:601-736-8282
Practice Address - Fax:601-736-8333
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-15
Last Update Date:2020-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS901706363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS01808562Medicaid