Provider Demographics
NPI:1700308806
Name:SHANNON, VAKESHEA (NP)
Entity Type:Individual
Prefix:
First Name:VAKESHEA
Middle Name:
Last Name:SHANNON
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 1:4381 S EASON BLVD STE 302
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38801-6584
Mailing Address - Country:US
Mailing Address - Phone:662-377-5700
Mailing Address - Fax:
Practice Address - Street 1:4381 S EASON BLVD STE 302
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38801-6584
Practice Address - Country:US
Practice Address - Phone:662-377-5700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-10
Last Update Date:2024-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS902133363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner