Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363L00000X | Nurse Practitioner | 0024-035946 | VA |
NPI | 1003888140 |
---|---|
Provider Name | Victoria Shelly |
First Address | Roanoke, VA 24018-7875 |
Second Address | Roanoke, VA 24019-4021 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 03/02/2006 |
Last Update Date | 24/04/2008 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
S48154 | (02) | VA |