Provider Demographics
NPI:1255425922
Name:CHURCHILL COY, SHAWN FORTENBERRY (FNP-BC, PMHNP-BC)
Entity type:Individual
Prefix:MRS
First Name:SHAWN
Middle Name:FORTENBERRY
Last Name:CHURCHILL COY
Suffix:
Gender:
Credentials:FNP-BC, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 26
Mailing Address - Street 2:
Mailing Address - City:CLIFTON
Mailing Address - State:TN
Mailing Address - Zip Code:38425-0026
Mailing Address - Country:US
Mailing Address - Phone:601-942-1855
Mailing Address - Fax:
Practice Address - Street 1:1331 CITY AVE N
Practice Address - Street 2:
Practice Address - City:RIPLEY
Practice Address - State:MS
Practice Address - Zip Code:38663-1102
Practice Address - Country:US
Practice Address - Phone:662-993-9336
Practice Address - Fax:662-993-9338
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2025-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS905512363LF0000X, 363LP0808X
MSR789934163WR0006X
TNAPN0000032347363LF0000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WR0006XNursing Service ProvidersRegistered NurseRegistered Nurse First Assistant
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health