Provider Demographics
NPI:1811209208
Name:SHACKELFORD, DILLETA ANDREE (APRN)
Entity Type:Individual
Prefix:
First Name:DILLETA
Middle Name:ANDREE
Last Name:SHACKELFORD
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:520 GRIFFIN AVE
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31601-6331
Mailing Address - Country:US
Mailing Address - Phone:229-249-6302
Mailing Address - Fax:229-249-4009
Practice Address - Street 1:520 GRIFFIN AVE
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31601-6331
Practice Address - Country:US
Practice Address - Phone:229-249-6302
Practice Address - Fax:229-249-4009
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-14
Last Update Date:2010-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN080625363LX0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0106XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerOccupational Health