Provider Demographics
NPI:1790197416
Name:AGNEW, SHAWANDA NECHELLA (MD)
Entity Type:Individual
Prefix:
First Name:SHAWANDA
Middle Name:NECHELLA
Last Name:AGNEW
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3629 WILLIAMS BROOKE LN
Mailing Address - Street 2:
Mailing Address - City:HERNANDO
Mailing Address - State:MS
Mailing Address - Zip Code:38632-6793
Mailing Address - Country:US
Mailing Address - Phone:662-401-3380
Mailing Address - Fax:
Practice Address - Street 1:7736 AIRWAYS BLVD
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-5306
Practice Address - Country:US
Practice Address - Phone:662-772-5222
Practice Address - Fax:662-772-5957
Is Sole Proprietor?:No
Enumeration Date:2014-05-29
Last Update Date:2024-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN61110207Q00000X
ALL.4005R207Q00000X
MS24203207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine