Provider Demographics
NPI:1538430087
Name:GOLDMAN, SHENETTA (FNP)
Entity type:Individual
Prefix:MS
First Name:SHENETTA
Middle Name:
Last Name:GOLDMAN
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3502 W NORTHSIDE DRIVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39213-2617
Mailing Address - Country:US
Mailing Address - Phone:601-364-5130
Mailing Address - Fax:
Practice Address - Street 1:3502 W NORTHSIDE DRIVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39213-3467
Practice Address - Country:US
Practice Address - Phone:601-364-5130
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-14
Last Update Date:2013-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR864623363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily