Provider Demographics
NPI:1710256037
Name:HERBERT, FANIKA SHUNTAE
Entity Type:Individual
Prefix:MRS
First Name:FANIKA
Middle Name:SHUNTAE
Last Name:HERBERT
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:FANIKA
Other - Middle Name:SHUNTAE
Other - Last Name:ADAMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:101 HOLMAN ST
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL SPRINGS
Mailing Address - State:MS
Mailing Address - Zip Code:39059-2582
Mailing Address - Country:US
Mailing Address - Phone:601-201-1130
Mailing Address - Fax:
Practice Address - Street 1:2500 N STATE ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4500
Practice Address - Country:US
Practice Address - Phone:601-984-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-14
Last Update Date:2011-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR882847163WM0705X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical