Provider Demographics
NPI:1730295619
Name:PAGE, SHIRLEY C (FNP)
Entity Type:Individual
Prefix:
First Name:SHIRLEY
Middle Name:C
Last Name:PAGE
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 S 28TH AVE
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401-7246
Mailing Address - Country:US
Mailing Address - Phone:601-268-5700
Mailing Address - Fax:601-579-5240
Practice Address - Street 1:415 S 28TH AVE
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39401-7246
Practice Address - Country:US
Practice Address - Phone:601-268-5700
Practice Address - Fax:601-268-5777
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2020-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR634875363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09550526Medicaid
GA812683366AMedicaid
MS9724412OtherAETNA
MSP00974932OtherRAILROAD MEDICARE
MSP00622808OtherRAILROAD MEDICARE
MSP00815523OtherRAILROAD MCARE THRU HCCN
LA1049336Medicaid
MSP00815523OtherRAILROAD MCARE THRU HCCN
GA812683366AMedicaid
MS9724412OtherAETNA
LA3B414DV13Medicare PIN
MS302I506600Medicare PIN
LA3B414DL36Medicare PIN