Provider Demographics
NPI:1104347814
Name:DOCKERY, SHASTA (RN)
Entity type:Individual
Prefix:
First Name:SHASTA
Middle Name:
Last Name:DOCKERY
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:SHASTA
Other - Middle Name:
Other - Last Name:DAVIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:15020 WADE BLVD
Mailing Address - Street 2:
Mailing Address - City:NORTH LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72113-6876
Mailing Address - Country:US
Mailing Address - Phone:501-231-9732
Mailing Address - Fax:
Practice Address - Street 1:15020 WADE BLVD.
Practice Address - Street 2:
Practice Address - City:NORTH LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72113
Practice Address - Country:US
Practice Address - Phone:501-231-9732
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-03
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARR104622163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse