Provider Demographics
NPI:1255425922
Name:CHURCHILL COY, SHAWN FORTENBERRY (FNP-BC, PMHNP-BC)
Entity type:Individual
Prefix:MRS
First Name:SHAWN
Middle Name:FORTENBERRY
Last Name:CHURCHILL COY
Suffix:
Gender:F
Credentials:FNP-BC, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3600 BLUECUTT RD STE 201
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:MS
Mailing Address - Zip Code:39705-1397
Mailing Address - Country:US
Mailing Address - Phone:601-942-1855
Mailing Address - Fax:662-329-9056
Practice Address - Street 1:3600 BLUECUTT RD STE 201
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:MS
Practice Address - Zip Code:39705-1397
Practice Address - Country:US
Practice Address - Phone:662-329-3973
Practice Address - Fax:662-329-9056
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2025-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR789934163WR0006X
MS905512363LF0000X, 363LP0808X
TNAPN0000032347363LF0000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WR0006XNursing Service ProvidersRegistered NurseRegistered Nurse First Assistant
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily