Healthcare Provider Details

I. General information

NPI: 1073909131
Provider Name (Legal Business Name): SHELBY NESTER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/15/2015
Last Update Date: 04/15/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9642 BURKE LAKE RD
BURKE VA
22015-3052
US

IV. Provider business mailing address

12906 NEW PARKLAND DR
HERNDON VA
20171-2645
US

V. Phone/Fax

Practice location:
  • Phone: 703-543-7920
  • Fax:
Mailing address:
  • Phone: 724-344-7526
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number2306603765
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: