Provider Demographics
NPI:1447347117
Name:SHACKELFORD, JUDITH D (CRNA)
Entity type:Individual
Prefix:
First Name:JUDITH
Middle Name:D
Last Name:SHACKELFORD
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 11302
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25339-1302
Mailing Address - Country:US
Mailing Address - Phone:304-346-9400
Mailing Address - Fax:304-720-8461
Practice Address - Street 1:FAIRMONT GENERAL HOSPITAL
Practice Address - Street 2:1325 LOCUST AVENUE
Practice Address - City:FAIRMONT
Practice Address - State:WV
Practice Address - Zip Code:26554
Practice Address - Country:US
Practice Address - Phone:304-367-7267
Practice Address - Fax:304-367-7503
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2008-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV18137367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV001907661OtherMSBCBS
WV001721190OtherMTN. STATE BLUE CROSS
WV0066583000Medicaid
WV3810006746Medicaid
WVDF0767OtherRR MEDICARE
WV205542387OtherAAP TRI CARE
WVP00377021OtherRR MEDICARE
WV0166583000Medicaid
WV20554238700OtherWORKERS COMP
WV8219671Medicare PIN
WV205542387OtherAAP TRI CARE
WV0166583000Medicaid
WV9364011Medicare PIN