Healthcare Provider Details

I. General information

NPI: 1528074374
Provider Name (Legal Business Name): LISA J SHACKELFORD CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3024 STADIUM BLVD
JONESBORO AR
72401-7415
US

IV. Provider business mailing address

304 COUNTY ROAD 388
JONESBORO AR
72401-0184
US

V. Phone/Fax

Practice location:
  • Phone: 501-227-0700
  • Fax: 501-227-0744
Mailing address:
  • Phone: 870-972-5478
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberCTP-000011
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: