Provider Demographics
NPI:1558471102
Name:SHACKELFORD, MAUREEN (RD CDE LD MA)
Entity Type:Individual
Prefix:
First Name:MAUREEN
Middle Name:
Last Name:SHACKELFORD
Suffix:
Gender:F
Credentials:RD CDE LD MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 ELGIN CT
Mailing Address - Street 2:
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21403-4358
Mailing Address - Country:US
Mailing Address - Phone:410-267-0259
Mailing Address - Fax:
Practice Address - Street 1:2001 MEDICAL PKWY
Practice Address - Street 2:
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21401-3280
Practice Address - Country:US
Practice Address - Phone:443-481-5368
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD717104133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDE021Medicare ID - Type Unspecified