MEDICARE: ANGELA L SHAW RN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	4704262265	MI

General Provider Information

NPI Number	:	1316372071
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANGELA L SHAW RN

Provider Business Mailing Address
First Line	:	585 JEWETT RD
Second Line	:
City	:	MASON
State	:	MI
Zip	:	48854-8729
Country	:	US
Telephone Number	:	517-676-5405
Fax Number	:	517-676-5460

Provider Business Practice Location Address
First Line	:	2233 W PARNALL RD
Second Line	:
City	:	JACKSON
State	:	MI
Zip	:	49201-9000
Country	:	US
Telephone Number	:	517-612-2290
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/12/2013
Last Update Date	:	09/12/2013

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