Provider Demographics
NPI:1740397983
Name:SHIVELY, TERESA ANN (BSN)
Entity Type:Individual
Prefix:MRS
First Name:TERESA
Middle Name:ANN
Last Name:SHIVELY
Suffix:
Gender:F
Credentials:BSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1649 HUNTING CREEK DR
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22314-6219
Mailing Address - Country:US
Mailing Address - Phone:703-704-6199
Mailing Address - Fax:
Practice Address - Street 1:8850 RICHMOND HWY STE 202
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22309-1586
Practice Address - Country:US
Practice Address - Phone:703-704-7004
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001149341163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0400XNursing Service ProvidersRegistered NurseCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0001149341OtherNURSING LICENSE