Provider Demographics
NPI:1033377833
Name:SHACKELFORD, BRENNA MAE (MD)
Entity Type:Individual
Prefix:DR
First Name:BRENNA
Middle Name:MAE
Last Name:SHACKELFORD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:745 W MOANA LN STE 300
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89509-4980
Mailing Address - Country:US
Mailing Address - Phone:775-327-5174
Mailing Address - Fax:
Practice Address - Street 1:745 W MOANA LN STE 300
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89509-4980
Practice Address - Country:US
Practice Address - Phone:775-327-5174
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-28
Last Update Date:2023-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01067626A207P00000X
HIMD19340207P00000X
NV23824207P00000X
CAA133488207P00000X
IDM15461207P00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program