Provider Demographics
NPI:1386167799
Name:RENICK, SHANNON D (DNP, APNP, CPNP-PC)
Entity type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:D
Last Name:RENICK
Suffix:
Gender:F
Credentials:DNP, APNP, CPNP-PC
Other - Prefix:MS
Other - First Name:SHANNON
Other - Middle Name:D
Other - Last Name:GRAHAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DNP, APNP, CPNP-PC
Mailing Address - Street 1:201 INDEPENDENCE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:MS
Mailing Address - Zip Code:39710-5300
Mailing Address - Country:US
Mailing Address - Phone:624-341-3956
Mailing Address - Fax:
Practice Address - Street 1:210 INDEPENDENCE AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:MS
Practice Address - Zip Code:39710-1269
Practice Address - Country:US
Practice Address - Phone:662-434-1395
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-18
Last Update Date:2025-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS907042363LP0200X
WI7787-33363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics