Provider Demographics
NPI:1487053740
Name:FORD, SHATESSIE MARIE (CRT)
Entity type:Individual
Prefix:MS
First Name:SHATESSIE
Middle Name:MARIE
Last Name:FORD
Suffix:
Gender:F
Credentials:CRT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:308 S GATLIN ST
Mailing Address - Street 2:
Mailing Address - City:OKOLONA
Mailing Address - State:MS
Mailing Address - Zip Code:38860-2005
Mailing Address - Country:US
Mailing Address - Phone:662-322-0340
Mailing Address - Fax:
Practice Address - Street 1:211 E MAIN ST
Practice Address - Street 2:
Practice Address - City:OKOLONA
Practice Address - State:MS
Practice Address - Zip Code:38860-1529
Practice Address - Country:US
Practice Address - Phone:662-322-0340
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-21
Last Update Date:2014-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS200003542332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies