Provider Demographics
NPI:1114324092
Name:SHIVELY, TRACEY
Entity Type:Individual
Prefix:MS
First Name:TRACEY
Middle Name:
Last Name:SHIVELY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14446 LAKE UNDERHILL RD
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32828-8121
Mailing Address - Country:US
Mailing Address - Phone:407-275-7192
Mailing Address - Fax:
Practice Address - Street 1:14446 LAKE UNDERHILL RD
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32828-8121
Practice Address - Country:US
Practice Address - Phone:407-275-7192
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-20
Last Update Date:2014-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator