Basic Information
| Provider Information | |||||||||
| NPI: | 1528208774 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHAMBLIN | ||||||||
| FirstName: | LUCY | ||||||||
| MiddleName: | KARA | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 12 KANAWHA TER | ||||||||
| Address2: | |||||||||
| City: | SAINT ALBANS | ||||||||
| State: | WV | ||||||||
| PostalCode: | 251772750 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3042011130 | ||||||||
| FaxNumber: | 3042011134 | ||||||||
| Practice Location | |||||||||
| Address1: | 12 KANAWHA TER | ||||||||
| Address2: | |||||||||
| City: | SAINT ALBANS | ||||||||
| State: | WV | ||||||||
| PostalCode: | 251772750 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3042011130 | ||||||||
| FaxNumber: | 3042011134 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/01/2009 | ||||||||
| LastUpdateDate: | 04/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/21/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207Q00000X | 2473 | WV | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | WV2180D | 01 | WV | MEDICARE PTAN | OTHER | WV2180E | 01 | WV | MEDICARE PTAN | OTHER | 003577627 | 01 | WV | UHC MPIN | OTHER | WV2080H | 01 | WV | MEDICARE PTAN | OTHER | 3810024964 | 05 | WV | MEDICAID | WV2180F | 01 | WV | MEDICARE PTAN | OTHER | WV2180G | 01 | WV | MEDICAARE PTAN | OTHER |