Basic Information
| Provider Information | |||||||||
| NPI: | 1821593724 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHACKLEFORD | ||||||||
| FirstName: | VIOLET | ||||||||
| MiddleName: | PATTY | ||||||||
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| OtherOrganizationName: | |||||||||
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| OtherLastName: | PATTY | ||||||||
| OtherFirstName: | VIOLET | ||||||||
| OtherMiddleName: | SAVANNAH | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1 MEDICAL CENTER DRIVE, ROOM 4601 | ||||||||
| Address2: | PO BOX 9238 | ||||||||
| City: | MORGANTOWN | ||||||||
| State: | WV | ||||||||
| PostalCode: | 26506 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3045980430 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1 MEDICAL CENTER DRIVE, ROOM 4601 | ||||||||
| Address2: | |||||||||
| City: | MORGANTOWN | ||||||||
| State: | WV | ||||||||
| PostalCode: | 26506 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3045980430 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/24/2018 | ||||||||
| LastUpdateDate: | 03/24/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.