Healthcare Provider Details

I. General information

NPI: 1093030967
Provider Name (Legal Business Name): EVA JANE SHAW CPNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2010
Last Update Date: 04/02/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6618 VAN NUYS BLVD
VAN NUYS CA
91405-4617
US

IV. Provider business mailing address

15477 VENTURA BLVD THIRD FLOOR
SHERMAN OAKS CA
91403-3006
US

V. Phone/Fax

Practice location:
  • Phone: 818-908-9962
  • Fax: 818-908-9914
Mailing address:
  • Phone: 818-907-0322
  • Fax: 818-907-0360

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number311173
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberNP 8710
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: