Provider Demographics
NPI:1649541103
Name:KELLEY, SHATIKA NICOLE (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:SHATIKA
Middle Name:NICOLE
Last Name:KELLEY
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5814 QUIET PINE CIR
Mailing Address - Street 2:APT 202
Mailing Address - City:CHESTER
Mailing Address - State:VA
Mailing Address - Zip Code:23831-7883
Mailing Address - Country:US
Mailing Address - Phone:757-383-5226
Mailing Address - Fax:
Practice Address - Street 1:5814 QUIET PINE CIR
Practice Address - Street 2:APT 202
Practice Address - City:CHESTER
Practice Address - State:VA
Practice Address - Zip Code:23831-7883
Practice Address - Country:US
Practice Address - Phone:757-383-5226
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-15
Last Update Date:2012-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2202005966235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist