Provider Demographics
NPI:1013596089
Name:DOYLE, SHAVONNE BRIDGETTE (NP)
Entity type:Individual
Prefix:
First Name:SHAVONNE
Middle Name:BRIDGETTE
Last Name:DOYLE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2908 S LAMAR BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:MS
Mailing Address - Zip Code:38655-5375
Mailing Address - Country:US
Mailing Address - Phone:662-281-0112
Mailing Address - Fax:
Practice Address - Street 1:2908 S LAMAR BLVD STE 100
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:MS
Practice Address - Zip Code:38655-5375
Practice Address - Country:US
Practice Address - Phone:662-281-0112
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-06
Last Update Date:2024-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR904555363LA2200X, 363LG0600X, 207RG0300X
TN904555207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Multi-Specialty
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontologyGroup - Multi-Specialty