Provider Demographics
NPI:1366688459
Name:SHACKLEFORD, GLENDA
Entity Type:Individual
Prefix:MRS
First Name:GLENDA
Middle Name:
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 1:1532 CAROL CIR
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35228-3139
Mailing Address - Country:US
Mailing Address - Phone:205-705-6639
Mailing Address - Fax:
Practice Address - Street 1:1532 CAROL CIR
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35228-3139
Practice Address - Country:US
Practice Address - Phone:205-705-6639
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-19
Last Update Date:2008-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies