Provider Demographics
NPI:1861037798
Name:SHACKELFORD, NATY JANE DEMONTEVERDE (RN BSN, AG-ACNP)
Entity Type:Individual
Prefix:MRS
First Name:NATY JANE
Middle Name:DEMONTEVERDE
Last Name:SHACKELFORD
Suffix:
Gender:F
Credentials:RN BSN, AG-ACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13409 GEORGIA HOLLOW COURT
Mailing Address - Street 2:
Mailing Address - City:ROSHARON
Mailing Address - State:TX
Mailing Address - Zip Code:77583-2278
Mailing Address - Country:US
Mailing Address - Phone:281-827-9689
Mailing Address - Fax:
Practice Address - Street 1:13409 GEORGIA HOLLOW COURT
Practice Address - Street 2:
Practice Address - City:ROSHARON
Practice Address - State:TX
Practice Address - Zip Code:77583-2278
Practice Address - Country:US
Practice Address - Phone:281-827-9689
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-14
Last Update Date:2020-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX715619163WM0705X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical