Provider Demographics
NPI:1609763812
Name:SHIELDS, KRISTIAN
Entity type:Individual
Prefix:
First Name:KRISTIAN
Middle Name:
Last Name:SHIELDS
Suffix:
Gender:X
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:122 RICHMOND WAY
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MS
Mailing Address - Zip Code:39046-6000
Mailing Address - Country:US
Mailing Address - Phone:769-990-8040
Mailing Address - Fax:
Practice Address - Street 1:604 HIGHWAY 80 W
Practice Address - Street 2:SUITE R OFFICE 2
Practice Address - City:CLINTON
Practice Address - State:MS
Practice Address - Zip Code:39056-4108
Practice Address - Country:US
Practice Address - Phone:601-473-2106
Practice Address - Fax:601-473-2150
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-20
Last Update Date:2025-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator