Provider Demographics
NPI:1790289510
Name:THEDFORD, SHANA (RO)
Entity Type:Individual
Prefix:
First Name:SHANA
Middle Name:
Last Name:THEDFORD
Suffix:
Gender:F
Credentials:RO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3220 LAUDERDALE RD
Mailing Address - Street 2:
Mailing Address - City:LAUDERDALE
Mailing Address - State:MS
Mailing Address - Zip Code:39335-9639
Mailing Address - Country:US
Mailing Address - Phone:601-616-1210
Mailing Address - Fax:601-483-7983
Practice Address - Street 1:3126 8TH ST.
Practice Address - Street 2:MAGNOLIA PLAZA SUITE A.
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39301-3930
Practice Address - Country:US
Practice Address - Phone:601-207-5085
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-19
Last Update Date:2022-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS156FC0800X, 156FX1101X, 156FX1800X
156FX1700X, 156FX1800X, 251V00000X, 156FX1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1101XEye and Vision Services ProvidersTechnician/TechnologistOphthalmic Assistant
No156FC0800XEye and Vision Services ProvidersTechnician/TechnologistContact Lens
No156FX1700XEye and Vision Services ProvidersTechnician/TechnologistOcularist
No156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
No251V00000XAgenciesVoluntary or Charitable
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS05986512Medicaid
NC16999022OtherCERTIFIED CHILDREN'S VISION SCREENER