Provider Demographics
NPI:1942828942
Name:SHUTZ, BRENDA DARNETTA
Entity type:Individual
Prefix:
First Name:BRENDA
Middle Name:DARNETTA
Last Name:SHUTZ
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 1:1505 RIVERSIDE DR
Mailing Address - Street 2:
Mailing Address - City:GAUTIER
Mailing Address - State:MS
Mailing Address - Zip Code:39553-2850
Mailing Address - Country:US
Mailing Address - Phone:228-623-3319
Mailing Address - Fax:
Practice Address - Street 1:330B HIGHWAY 90
Practice Address - Street 2:
Practice Address - City:GAUTIER
Practice Address - State:MS
Practice Address - Zip Code:39553-5744
Practice Address - Country:US
Practice Address - Phone:228-497-0690
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-07
Last Update Date:2020-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS510505163WR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WR0400XNursing Service ProvidersRegistered NurseRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00018214Medicaid