Provider Demographics
NPI:1811246531
Name:VELICKOFF, SHELLEY L (ANP)
Entity type:Individual
Prefix:MRS
First Name:SHELLEY
Middle Name:L
Last Name:VELICKOFF
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 SAGAMORE PKWY W.
Mailing Address - Street 2:
Mailing Address - City:WEST LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47906
Mailing Address - Country:US
Mailing Address - Phone:765-463-6722
Mailing Address - Fax:765-463-0905
Practice Address - Street 1:124 SAGAMORE PKWY W.
Practice Address - Street 2:
Practice Address - City:WEST LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47906
Practice Address - Country:US
Practice Address - Phone:765-463-6722
Practice Address - Fax:765-463-0905
Is Sole Proprietor?:No
Enumeration Date:2012-09-10
Last Update Date:2024-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP60277759363L00000X
IN71011005A207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner