Provider Demographics
NPI:1790289510
Name:THEDFORD, SHANA (RO)
Entity type:Individual
Prefix:
First Name:SHANA
Middle Name:
Last Name:THEDFORD
Suffix:
Gender:F
Credentials:RO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3220 LAUDERDALE RD
Mailing Address - Street 2:
Mailing Address - City:LAUDERDALE
Mailing Address - State:MS
Mailing Address - Zip Code:39335-9639
Mailing Address - Country:US
Mailing Address - Phone:601-616-1210
Mailing Address - Fax:601-483-7983
Practice Address - Street 1:3304 8TH ST
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39301-4755
Practice Address - Country:US
Practice Address - Phone:844-225-7160
Practice Address - Fax:386-343-7195
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-19
Last Update Date:2025-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS156FC0800X, 156FX1101X, 156FX1800X
156FX1101X, 156FX1700X, 156FX1800X, 251V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1101XEye and Vision Services ProvidersTechnician/TechnologistOphthalmic AssistantGroup - Single Specialty
No156FC0800XEye and Vision Services ProvidersTechnician/TechnologistContact Lens
No156FX1700XEye and Vision Services ProvidersTechnician/TechnologistOcularist
No156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
No251V00000XAgenciesVoluntary or CharitableGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS05986512Medicaid
NC16999022OtherCERTIFIED CHILDREN'S VISION SCREENER