Provider Demographics
NPI:1720036890
Name:WHITE, SHELBY T (CNFP)
Entity Type:Individual
Prefix:MR
First Name:SHELBY
Middle Name:T
Last Name:WHITE
Suffix:
Gender:M
Credentials:CNFP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P. O. BOX 511
Mailing Address - Street 2:
Mailing Address - City:LIBERTY
Mailing Address - State:MS
Mailing Address - Zip Code:39645-0511
Mailing Address - Country:US
Mailing Address - Phone:601-657-4326
Mailing Address - Fax:601-657-8867
Practice Address - Street 1:102 WEST FREEDROM DRIVE
Practice Address - Street 2:
Practice Address - City:LIBERTY
Practice Address - State:MS
Practice Address - Zip Code:39645-0511
Practice Address - Country:US
Practice Address - Phone:601-657-4326
Practice Address - Fax:601-657-8867
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR861790363L00000X
MST-4868207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08923390Medicaid
MS500001953Medicare ID - Type Unspecified
MS08923390Medicaid