Provider Demographics
NPI:1669682860
Name:SHACKELFORD, DONNA RENEE (LVN)
Entity type:Individual
Prefix:MS
First Name:DONNA
Middle Name:RENEE
Last Name:SHACKELFORD
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:650 HOWE AVE
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95825-4731
Mailing Address - Country:US
Mailing Address - Phone:916-441-0123
Mailing Address - Fax:
Practice Address - Street 1:14277 ROAD 28
Practice Address - Street 2:
Practice Address - City:MADERA
Practice Address - State:CA
Practice Address - Zip Code:93638-5715
Practice Address - Country:US
Practice Address - Phone:559-673-3508
Practice Address - Fax:559-681-2818
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-23
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN204836164X00000X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health