Provider Demographics
NPI:1194947754
Name:PHELON, SHONDA JACQUELINE (CFNP; PMHNP)
Entity type:Individual
Prefix:
First Name:SHONDA
Middle Name:JACQUELINE
Last Name:PHELON
Suffix:
Gender:F
Credentials:CFNP; PMHNP
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 1505
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:38935-1505
Mailing Address - Country:US
Mailing Address - Phone:662-453-6211
Mailing Address - Fax:
Practice Address - Street 1:1970 GRANDVIEW DR
Practice Address - Street 2:
Practice Address - City:GRENADA
Practice Address - State:MS
Practice Address - Zip Code:38901-5066
Practice Address - Country:US
Practice Address - Phone:662-227-3700
Practice Address - Fax:662-227-3740
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2010-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR734347363LF0000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00113141Medicare UPIN