Provider Demographics
NPI:1295249415
Name:SHIVELY, KYRA MONIQUE
Entity type:Individual
Prefix:MS
First Name:KYRA
Middle Name:MONIQUE
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 1:3049 CRIMSON RANCH LN
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49685-9767
Mailing Address - Country:US
Mailing Address - Phone:231-239-2468
Mailing Address - Fax:
Practice Address - Street 1:3205 SUPPLY RD
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49696-9486
Practice Address - Country:US
Practice Address - Phone:231-935-1070
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-27
Last Update Date:2018-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704339826163W00000X
MI4703119005164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No164W00000XNursing Service ProvidersLicensed Practical Nurse