Provider Demographics
NPI:1073214540
Name:SHACKLEFORD, RICHI MICHELE (NP)
Entity Type:Individual
Prefix:
First Name:RICHI
Middle Name:MICHELE
Last Name:SHACKLEFORD
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8786 KY 459
Mailing Address - Street 2:
Mailing Address - City:BARBOURVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40906-7236
Mailing Address - Country:US
Mailing Address - Phone:606-243-5108
Mailing Address - Fax:
Practice Address - Street 1:1 TRILLIUM WAY
Practice Address - Street 2:
Practice Address - City:CORBIN
Practice Address - State:KY
Practice Address - Zip Code:40701-8426
Practice Address - Country:US
Practice Address - Phone:606-528-1212
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-13
Last Update Date:2023-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3018730363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner