Provider Demographics
NPI:1811774417
Name:SHACKELFORD, KENNETH RYAN (DNP, APRN, FNP-BC)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:RYAN
Last Name:SHACKELFORD
Suffix:
Gender:M
Credentials:DNP, APRN, FNP-BC
Other - Prefix:
Other - First Name:KENNETH
Other - Middle Name:RYAN
Other - Last Name:HESS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:16607 EVERGREEN FOREST DR
Mailing Address - Street 2:
Mailing Address - City:WILDWOOD
Mailing Address - State:MO
Mailing Address - Zip Code:63011-1800
Mailing Address - Country:US
Mailing Address - Phone:314-379-4344
Mailing Address - Fax:
Practice Address - Street 1:1405 N TRUMAN BLVD
Practice Address - Street 2:
Practice Address - City:FESTUS
Practice Address - State:MO
Practice Address - Zip Code:63028-1177
Practice Address - Country:US
Practice Address - Phone:636-933-2243
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-08
Last Update Date:2023-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2023036843363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily