Provider Demographics
NPI:1669764544
Name:MUCKLOW, SHAUNA
Entity type:Individual
Prefix:
First Name:SHAUNA
Middle Name:
Last Name:MUCKLOW
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 1:2304 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:KEARNEY
Mailing Address - State:NE
Mailing Address - Zip Code:68847-5349
Mailing Address - Country:US
Mailing Address - Phone:308-237-3044
Mailing Address - Fax:308-237-3051
Practice Address - Street 1:2304 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:KEARNEY
Practice Address - State:NE
Practice Address - Zip Code:68847-5349
Practice Address - Country:US
Practice Address - Phone:308-237-3044
Practice Address - Fax:308-237-3051
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-10
Last Update Date:2011-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE001009538704171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025378300Medicaid