Individual
JUDITH D SHACKELFORD
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
CRNA
Contact information
Practice address
FAIRMONT GENERAL HOSPITAL, 1325 LOCUST AVENUE, FAIRMONT, WV 26554
(304) 367-7267
(304) 367-7503
Mailing address
PO BOX 11302, CHARLESTON, WV 25339-1302
(304) 346-9400
(304) 720-8461
Taxonomy
Speciality
Code
Description
License number
State
367500000X
Certified Registered Nurse Anesthetist
Primary
18137
WV
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
001721190
MTN. STATE BLUE CROSS
WV
01
—
001907661
MSBCBS
WV
05
—
0066583000
—
WV
05
—
0166583000
—
WV
01
—
205542387
AAP TRI CARE
WV
01
—
20554238700
WORKERS COMP
WV
05
—
3810006746
—
WV
01
—
DF0767
RR MEDICARE
WV
01
—
P00377021
RR MEDICARE
WV
Enumeration date
10/06/2006
Last updated
05/14/2008
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