Provider Demographics
NPI:1598353294
Name:PETIN, SHELLEY NICOLE (PHARMD)
Entity Type:Individual
Prefix:
First Name:SHELLEY
Middle Name:NICOLE
Last Name:PETIN
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7300 MARKET PLACE DR
Mailing Address - Street 2:
Mailing Address - City:QUINTON
Mailing Address - State:VA
Mailing Address - Zip Code:23141-1639
Mailing Address - Country:US
Mailing Address - Phone:804-932-8835
Mailing Address - Fax:
Practice Address - Street 1:7300 MARKET PLACE DR
Practice Address - Street 2:
Practice Address - City:QUINTON
Practice Address - State:VA
Practice Address - Zip Code:23141-1639
Practice Address - Country:US
Practice Address - Phone:804-932-8835
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-07
Last Update Date:2021-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA02022053482255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer