Provider Demographics
NPI:1396302519
Name:SHANKLE, CICELY
Entity type:Individual
Prefix:
First Name:CICELY
Middle Name:
Last Name:SHANKLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 UNIVERSITY AVE STE 2A
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99709-3651
Mailing Address - Country:US
Mailing Address - Phone:907-206-3000
Mailing Address - Fax:907-331-0480
Practice Address - Street 1:600 UNIVERSITY AVE STE 2A
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99709-3651
Practice Address - Country:US
Practice Address - Phone:907-206-3000
Practice Address - Fax:907-331-0480
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-22
Last Update Date:2021-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK146810133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist