Provider Demographics
NPI:1053740316
Name:SHAKLEFORD, COLEEN (LPN)
Entity type:Individual
Prefix:
First Name:COLEEN
Middle Name:
Last Name:SHAKLEFORD
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3207 TENBROECK AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10469-5010
Mailing Address - Country:US
Mailing Address - Phone:347-478-4037
Mailing Address - Fax:
Practice Address - Street 1:3207 TENBROECK AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10469-5010
Practice Address - Country:US
Practice Address - Phone:347-478-4037
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-07
Last Update Date:2013-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY316840164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse