Provider Demographics
NPI:1700495819
Name:SHACKLETON, MEGHAN JO (NP-C)
Entity Type:Individual
Prefix:
First Name:MEGHAN
Middle Name:JO
Last Name:SHACKLETON
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 CALIFORNIA ST
Mailing Address - Street 2:PO BOX 577
Mailing Address - City:CARTERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62918-0577
Mailing Address - Country:US
Mailing Address - Phone:618-519-9200
Mailing Address - Fax:
Practice Address - Street 1:3111 WILLIAMSON COUNTY PKWY
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IL
Practice Address - Zip Code:62959-5235
Practice Address - Country:US
Practice Address - Phone:618-519-9200
Practice Address - Fax:618-985-9155
Is Sole Proprietor?:No
Enumeration Date:2020-07-24
Last Update Date:2022-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.021677363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily