Provider Demographics
NPI:1003888447
Name:SHACKLEFORD, DOROTHY LORRAINE
Entity Type:Individual
Prefix:
First Name:DOROTHY
Middle Name:LORRAINE
Last Name:SHACKLEFORD
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 1:68 SOUTH SERVICE ROAD
Mailing Address - Street 2:SUITE 350
Mailing Address - City:MELVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11545-2358
Mailing Address - Country:US
Mailing Address - Phone:516-945-3000
Mailing Address - Fax:516-945-3131
Practice Address - Street 1:3963 HARTLAKE ST
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22192-7477
Practice Address - Country:US
Practice Address - Phone:703-590-2019
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-01
Last Update Date:2015-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA598148367500000X
VA0001212718367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1003888447Medicaid
VAP01179302OtherRAILROAD MEDICARE
VA223354YRNMedicare PIN