Provider Demographics
NPI:1275027617
Name:SHACKLE, PATRICE A
Entity Type:Individual
Prefix:
First Name:PATRICE
Middle Name:A
Last Name:SHACKLE
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 1:1575 YAUGER RD APT 5
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:OH
Mailing Address - Zip Code:43050-9085
Mailing Address - Country:US
Mailing Address - Phone:740-326-1777
Mailing Address - Fax:
Practice Address - Street 1:117 W HIGH ST
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:OH
Practice Address - Zip Code:43050-2425
Practice Address - Country:US
Practice Address - Phone:740-392-9491
Practice Address - Fax:740-392-9165
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-19
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH171M00000X, 175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No175T00000XOther Service ProvidersPeer Specialist