Provider Demographics
NPI:1255484481
Name:KING, THERESA SHELLY (RCP)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:SHELLY
Last Name:KING
Suffix:
Gender:F
Credentials:RCP
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 822394
Mailing Address - Street 2:
Mailing Address - City:VICKSBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39182-2394
Mailing Address - Country:US
Mailing Address - Phone:601-638-4076
Mailing Address - Fax:601-638-4979
Practice Address - Street 1:1901 MISSION 66
Practice Address - Street 2:SUITE A
Practice Address - City:VICKSBURG
Practice Address - State:MS
Practice Address - Zip Code:39180-3711
Practice Address - Country:US
Practice Address - Phone:601-638-4076
Practice Address - Fax:601-638-4979
Is Sole Proprietor?:No
Enumeration Date:2007-01-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSRCP 12992278G1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2278G1100XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, CertifiedGeneral Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS7737511OtherAETNA #
MS25-4533Medicare ID - Type Unspecified