=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811209208
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DILLETA ANDREE SHACKELFORD APRN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/14/2010
-----------------------------------------------------
Last Update Date | 07/14/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 520 GRIFFIN AVE
-----------------------------------------------------
City | VALDOSTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31601-6331
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 229-249-6302
-----------------------------------------------------
Fax | 229-249-4009
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 520 GRIFFIN AVE
-----------------------------------------------------
City | VALDOSTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31601-6331
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 229-249-6302
-----------------------------------------------------
Fax | 229-249-4009
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LX0106X
-----------------------------------------------------
Taxonomy Name | Occupational Health Nurse Practitioner
-----------------------------------------------------
License Number | RN080625
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------