Provider Demographics
NPI:1750797874
Name:BOONE, SHELLY (CFNP)
Entity type:Individual
Prefix:
First Name:SHELLY
Middle Name:
Last Name:BOONE
Suffix:
Gender:F
Credentials:CFNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12953 HIGHWAY 501
Mailing Address - Street 2:
Mailing Address - City:FOREST
Mailing Address - State:MS
Mailing Address - Zip Code:39074-5647
Mailing Address - Country:US
Mailing Address - Phone:601-536-3979
Mailing Address - Fax:
Practice Address - Street 1:526 DEERFIELD DR
Practice Address - Street 2:
Practice Address - City:FOREST
Practice Address - State:MS
Practice Address - Zip Code:39074-6005
Practice Address - Country:US
Practice Address - Phone:601-469-0291
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-09
Last Update Date:2014-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR863942363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily