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General NPI Number Information
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NPI Number | 1033377833
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Entity Type | Individual
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Provider Name | BRENNA MAE SHACKELFORD MD
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Gender | Female
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Dates
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Enumeration Date | 05/28/2008
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Last Update Date | 08/06/2024
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Provider Practice Location Address
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Address Line | 520 S EAGLE RD STE 3102
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City | MERIDIAN
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State | ID
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Zip | 83642-6352
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Country | US
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Telephone | 208-381-1615
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Fax | 208-381-5141
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Provider Business Mailing Address
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Address Line | 190 E BANNOCK ST
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City | BOISE
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State | ID
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Zip | 83712-6241
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Country | US
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Telephone | 208-381-8752
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207P00000X
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Taxonomy Name | Emergency Medicine Physician
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License Number | MD19340
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License Number State | HI
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Taxonomy #2
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Taxonomy Code | 207P00000X
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Taxonomy Name | Emergency Medicine Physician
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License Number | 01067626A
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License Number State | IN
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Taxonomy #3
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Taxonomy Code | 207P00000X
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Taxonomy Name | Emergency Medicine Physician
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License Number | 23824
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License Number State | NV
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Taxonomy #4
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Taxonomy Code | 207P00000X
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Taxonomy Name | Emergency Medicine Physician
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License Number | A133488
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License Number State | CA
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Taxonomy #5
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Taxonomy Code | 207P00000X
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Taxonomy Name | Emergency Medicine Physician
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License Number | M15461
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License Number State | ID
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Taxonomy #6
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Taxonomy Code | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number |
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License Number State |
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Taxonomy #7
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Taxonomy Code | 207PH0002X
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Taxonomy Name | Hospice and Palliative Medicine (Emergency Medicine) Physician
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License Number | M-15461
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License Number State | ID
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