Healthcare Provider Details

I. General information

NPI: 1134058860
Provider Name (Legal Business Name): MRS. MALERIE SHACKLETON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2026
Last Update Date: 05/18/2026
Certification Date: 05/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1013 W UNIVERSITY AVE STE 193
GEORGETOWN TX
78628-5343
US

IV. Provider business mailing address

1100 STETSON HAT TRL
GEORGETOWN TX
78628-2596
US

V. Phone/Fax

Practice location:
  • Phone: 512-359-8349
  • Fax:
Mailing address:
  • Phone: 512-797-8447
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1234286
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: