MEDICARE: DR. KENNETH RYAN SHACKELFORD DNP, APRN, FNP-BC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	2023036843	MO

General Provider Information

NPI Number	:	1811774417
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KENNETH RYAN SHACKELFORD DNP, APRN, FNP-BC

Provider Business Mailing Address
First Line	:	16607 EVERGREEN FOREST DR
Second Line	:
City	:	WILDWOOD
State	:	MO
Zip	:	63011-1800
Country	:	US
Telephone Number	:	314-379-4344
Fax Number	:

Provider Business Practice Location Address
First Line	:	1405 N TRUMAN BLVD
Second Line	:
City	:	FESTUS
State	:	MO
Zip	:	63028-1177
Country	:	US
Telephone Number	:	636-933-2243
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/08/2023
Last Update Date	:	09/08/2023

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