Provider Demographics
NPI:1104107317
Name:SHACKELFORD, COLLEEN M (NP)
Entity type:Individual
Prefix:MRS
First Name:COLLEEN
Middle Name:M
Last Name:SHACKELFORD
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:COLLEEN
Other - Middle Name:MARIE
Other - Last Name:BENDER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:300 E BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6207
Mailing Address - Country:US
Mailing Address - Phone:208-342-7400
Mailing Address - Fax:208-342-1879
Practice Address - Street 1:300 E BANNOCK ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83712-6207
Practice Address - Country:US
Practice Address - Phone:208-342-7400
Practice Address - Fax:208-342-1879
Is Sole Proprietor?:No
Enumeration Date:2011-08-31
Last Update Date:2018-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDN-41423163W00000X
IDNP-1127A363LF0000X
IDNP1127A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse