Provider Demographics
NPI:1528946068
Name:SHACKLEFORD, AGNESS LATRICE
Entity type:Individual
Prefix:MRS
First Name:AGNESS
Middle Name:LATRICE
Last Name:SHACKLEFORD
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:AGNESS
Other - Middle Name:LATRICE
Other - Last Name:SHACKLEFORD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2566 TIFFIN ST
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48504-7704
Mailing Address - Country:US
Mailing Address - Phone:810-955-2902
Mailing Address - Fax:
Practice Address - Street 1:2566 TIFFIN ST
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48504-7704
Practice Address - Country:US
Practice Address - Phone:810-955-2902
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-22
Last Update Date:2025-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker