Provider Demographics
NPI:1023671617
Name:SHIVELY, NICOLE MAALOUF (PA)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:MAALOUF
Last Name:SHIVELY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1622 WESTOVER AVE SW
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24015-5216
Mailing Address - Country:US
Mailing Address - Phone:339-368-1887
Mailing Address - Fax:
Practice Address - Street 1:1622 WESTOVER AVE SW
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24015-5216
Practice Address - Country:US
Practice Address - Phone:339-368-1887
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-18
Last Update Date:2024-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-10795363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant