Healthcare Provider Details

I. General information

NPI: 1821593724
Provider Name (Legal Business Name): VIOLET PATTY SHACKLEFORD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: VIOLET SAVANNAH PATTY

II. Dates (important events)

Enumeration Date: 03/24/2018
Last Update Date: 09/25/2024
Certification Date: 09/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MEDICAL CENTER DRIVE, ROOM 4601
MORGANTOWN WV
26506
US

IV. Provider business mailing address

1 MEDICAL CENTER DRIVE, ROOM 4601 PO BOX 9238
MORGANTOWN WV
26506
US

V. Phone/Fax

Practice location:
  • Phone: 304-598-0430
  • Fax:
Mailing address:
  • Phone: 304-598-0430
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number29882
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number35.150401
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number59016
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: