Provider Demographics
NPI:1982083309
Name:SHIVELY, SARA (ATC)
Entity type:Individual
Prefix:
First Name:SARA
Middle Name:
Last Name:SHIVELY
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1222 W PROSPECT AVE
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:NE
Mailing Address - Zip Code:68701-3705
Mailing Address - Country:US
Mailing Address - Phone:308-940-1506
Mailing Address - Fax:
Practice Address - Street 1:1222 W PROSPECT AVE
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:NE
Practice Address - Zip Code:68701-3705
Practice Address - Country:US
Practice Address - Phone:308-940-1506
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-19
Last Update Date:2015-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE645174H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator