Provider Demographics
NPI:1487293262
Name:MURPHY, SHYLOH L
Entity type:Individual
Prefix:
First Name:SHYLOH
Middle Name:L
Last Name:MURPHY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11248 SHELTON RD
Mailing Address - Street 2:
Mailing Address - City:BASTROP
Mailing Address - State:LA
Mailing Address - Zip Code:71220-7614
Mailing Address - Country:US
Mailing Address - Phone:318-235-5737
Mailing Address - Fax:
Practice Address - Street 1:203 W JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:BASTROP
Practice Address - State:LA
Practice Address - Zip Code:71220-4543
Practice Address - Country:US
Practice Address - Phone:318-235-5737
Practice Address - Fax:318-283-8954
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-27
Last Update Date:2019-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization