Provider Demographics
NPI:1407524283
Name:FLUKER, SHADELL M
Entity Type:Individual
Prefix:
First Name:SHADELL
Middle Name:M
Last Name:FLUKER
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 1:2025 SHIMLA DR
Mailing Address - Street 2:
Mailing Address - City:BRYAN
Mailing Address - State:TX
Mailing Address - Zip Code:77807-1457
Mailing Address - Country:US
Mailing Address - Phone:979-777-3589
Mailing Address - Fax:
Practice Address - Street 1:801 S ENNIS ST
Practice Address - Street 2:
Practice Address - City:BRYAN
Practice Address - State:TX
Practice Address - Zip Code:77803-4642
Practice Address - Country:US
Practice Address - Phone:979-209-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-05
Last Update Date:2021-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX17465235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist