Basic Information
| Provider Information | |||||||||
| NPI: | 1447407895 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RIVES | ||||||||
| FirstName: | SHANNON | ||||||||
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| Credential: | N.P. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2500 N STATE ST | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392164500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6019846565 | ||||||||
| FaxNumber: | 6019845658 | ||||||||
| Practice Location | |||||||||
| Address1: | 1040 RIVER OAKS DR | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | FLOWOOD | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392329530 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6013262599 | ||||||||
| FaxNumber: | 6019330852 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/27/2008 | ||||||||
| LastUpdateDate: | 09/14/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | R820958 | MS | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 06286014 | 05 | MS | MEDICAID | 1336216431 | 01 | MS | GROUP NPI | OTHER |