Provider Demographics
NPI:1346594264
Name:SHETLEY, MICHAEL WAYNE (ATC, CSCS)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:WAYNE
Last Name:SHETLEY
Suffix:
Gender:M
Credentials:ATC, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:179 GLENN CARSON RD
Mailing Address - Street 2:
Mailing Address - City:PROSPECT
Mailing Address - State:VA
Mailing Address - Zip Code:23960-2112
Mailing Address - Country:US
Mailing Address - Phone:804-539-5080
Mailing Address - Fax:
Practice Address - Street 1:198 EVERGREEN AVE
Practice Address - Street 2:
Practice Address - City:APPOMATTOX
Practice Address - State:VA
Practice Address - Zip Code:24522
Practice Address - Country:US
Practice Address - Phone:804-539-5080
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-30
Last Update Date:2012-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01260004902255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer