Provider Demographics
NPI:1881251312
Name:SHELBURNE, CANDI DENISE (NNP-BC)
Entity type:Individual
Prefix:
First Name:CANDI
Middle Name:DENISE
Last Name:SHELBURNE
Suffix:
Gender:F
Credentials:NNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1117 HOUSTON ST
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38804-2519
Mailing Address - Country:US
Mailing Address - Phone:662-643-6377
Mailing Address - Fax:
Practice Address - Street 1:853 JEFFERSON AVE # E206
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38103-2804
Practice Address - Country:US
Practice Address - Phone:901-448-6728
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-21
Last Update Date:2019-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN25868363LN0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0005XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal, Critical Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN25868Medicaid