Provider Demographics
NPI:1376279513
Name:SHACKLEFORD, KIM (FNTP)
Entity Type:Individual
Prefix:MS
First Name:KIM
Middle Name:
Last Name:SHACKLEFORD
Suffix:
Gender:F
Credentials:FNTP
Other - Prefix:
Other - First Name:KIM
Other - Middle Name:
Other - Last Name:SHACKLEFORD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNTP
Mailing Address - Street 1:3830 CASEY LEIGH LN
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27612-4258
Mailing Address - Country:US
Mailing Address - Phone:919-427-5946
Mailing Address - Fax:
Practice Address - Street 1:3830 CASEY LEIGH LN
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27612-4258
Practice Address - Country:US
Practice Address - Phone:919-427-5946
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-29
Last Update Date:2022-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist