Provider Demographics
NPI:1023527017
Name:SHIELDS, KATHERINE WATERS (NP)
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:WATERS
Last Name:SHIELDS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:KATHERINE
Other - Middle Name:
Other - Last Name:WATERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:965 RIDGE LAKE BLVD STE 103
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38120-9446
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:901-227-8591
Practice Address - Street 1:100 BAPTIST MEMORIAL CIR STE 120
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:MS
Practice Address - Zip Code:38655-4476
Practice Address - Country:US
Practice Address - Phone:662-244-2288
Practice Address - Fax:662-636-2285
Is Sole Proprietor?:No
Enumeration Date:2017-09-22
Last Update Date:2021-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS902316363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily