Provider Demographics
NPI:1316653397
Name:SHACKELFORD, ALICE (FNP-C)
Entity type:Individual
Prefix:
First Name:ALICE
Middle Name:
Last Name:SHACKELFORD
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 296
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:MS
Mailing Address - Zip Code:39039-0296
Mailing Address - Country:US
Mailing Address - Phone:769-234-8311
Mailing Address - Fax:
Practice Address - Street 1:971 LAKELAND DR STE 950
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4608
Practice Address - Country:US
Practice Address - Phone:601-362-6900
Practice Address - Fax:601-362-6111
Is Sole Proprietor?:No
Enumeration Date:2023-01-24
Last Update Date:2023-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS905551363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily