Basic Information
| Provider Information | |||||||||
| NPI: | 1295982429 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHACKELL | ||||||||
| FirstName: | AMANDA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | APRN | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1 LONG WHARF DR | ||||||||
| Address2: | STE 321 | ||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065115991 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037814600 | ||||||||
| FaxNumber: | 2037814624 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 LONG WHARF DR | ||||||||
| Address2: | |||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065115991 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037814600 | ||||||||
| FaxNumber: | 2037814624 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/19/2008 | ||||||||
| LastUpdateDate: | 01/24/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/24/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | 002620 | CT | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 004217099 | 05 | CT | MEDICAID | 008023170 | 05 | CT | MEDICAID | 004082286 | 05 | CT | MEDICAID | 008024427 | 05 | CT | MEDICAID | 008003745 | 05 | CT | MEDICAID | 008022622 | 05 | CT | MEDICAID | 008037391 | 05 | CT | MEDICAID | 008039745 | 05 | CT | MEDICAID | 500000315 | 05 | CT | MEDICAID | C01033 | 01 | CT | MEDICARE IDENTIFICATION NUMBER | OTHER | 008022626 | 05 | CT | MEDICAID | 004041000 | 05 | CT | MEDICAID | 004082260 | 05 | CT | MEDICAID | 008001325 | 05 | CT | MEDICAID | 008042339 | 05 | CT | MEDICAID |