Provider Demographics
NPI:1164907283
Name:SHACKELFORD, BARBARA CRYSTAL (APRN)
Entity Type:Individual
Prefix:MRS
First Name:BARBARA
Middle Name:CRYSTAL
Last Name:SHACKELFORD
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:58 ISLETA DR
Mailing Address - Street 2:
Mailing Address - City:CHEROKEE VILLAGE
Mailing Address - State:AR
Mailing Address - Zip Code:72529-5013
Mailing Address - Country:US
Mailing Address - Phone:870-955-1234
Mailing Address - Fax:
Practice Address - Street 1:1995 HIGHWAY 62 412
Practice Address - Street 2:
Practice Address - City:HIGHLAND
Practice Address - State:AR
Practice Address - Zip Code:72542-9262
Practice Address - Country:US
Practice Address - Phone:870-856-5620
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-25
Last Update Date:2021-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA005877207Q00000X, 363LA2100X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR252346758Medicaid