Provider Demographics
NPI:1659130599
Name:SHIRLEY, MINNIE
Entity Type:Individual
Prefix:MRS
First Name:MINNIE
Middle Name:
Last Name:SHIRLEY
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 1:56 MAYFIELD RD
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MS
Mailing Address - Zip Code:39443-8459
Mailing Address - Country:US
Mailing Address - Phone:601-452-0084
Mailing Address - Fax:
Practice Address - Street 1:1506 N MAIN ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MS
Practice Address - Zip Code:39429-2070
Practice Address - Country:US
Practice Address - Phone:601-736-9557
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-14
Last Update Date:2024-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS905856363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily