Provider Demographics
NPI:1831912492
Name:MICKLEBERRY, SHIRLEY A
Entity type:Individual
Prefix:
First Name:SHIRLEY
Middle Name:A
Last Name:MICKLEBERRY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ANTOINE
Other - Middle Name:L
Other - Last Name:HENDERSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:403 STOCKTON ST APT 4217
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23224-4357
Mailing Address - Country:US
Mailing Address - Phone:804-464-7388
Mailing Address - Fax:
Practice Address - Street 1:403 STOCKTON ST APT 4217
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23224-4357
Practice Address - Country:US
Practice Address - Phone:804-464-7388
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-04
Last Update Date:2024-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAMC2400347SK343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)