Provider Demographics
NPI:1033377833
Name:SHACKELFORD, BRENNA MAE (MD)
Entity type:Individual
Prefix:DR
First Name:BRENNA
Middle Name:MAE
Last Name:SHACKELFORD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:190 E BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6241
Mailing Address - Country:US
Mailing Address - Phone:208-381-8752
Mailing Address - Fax:
Practice Address - Street 1:520 S EAGLE RD STE 3102
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-6352
Practice Address - Country:US
Practice Address - Phone:208-381-1615
Practice Address - Fax:208-381-5141
Is Sole Proprietor?:No
Enumeration Date:2008-05-28
Last Update Date:2024-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMD19340207P00000X
IN01067626A207P00000X
NV23824207P00000X
CAA133488207P00000X
IDM15461207P00000X
390200000X
IDM-15461207PH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PH0002XAllopathic & Osteopathic PhysiciansEmergency MedicineHospice and Palliative Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program