Rose Lee Shaddon, TAXI
Individual provider Active NPI Driver · Russellville, AR
NPI 1235833302 · NPPES record last updated Mar 30, 2023
Key facts
- NPI
- 1235833302
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Driver 172A00000X
- License
- 0421-016067 (AR)
- Practice address
- 705 Williamson Way
Russellville, AR 72801-6923 - Phone
- (479) 280-2132
- NPI assigned
- Mar 30, 2023
- Sex
- Female
- Sole proprietor
- No
Organizations & group practices 1
Medicare participation
- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
- Medicare enrollment (NPD)
- No
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 0421-016067 | AR | MD | Driver |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Serenity Evolution Care LLC | Current | Accepting new patients |
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Driver | 172A00000X | 0421-016067 | AR | Yes |
Addresses
Primary practice location
705 Williamson Way
Russellville, AR 72801-6923
Mailing address
705 Williamson Way
Russellville, AR 72801-6923
Phone (479) 280-2132
Other providers in Russellville, AR
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Mar 30, 2023. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.