Healthcare Provider Details

I. General information

NPI: 1396208260
Provider Name (Legal Business Name): STEPHANIE SHAW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2019
Last Update Date: 06/15/2020
Certification Date: 06/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7031 SW 62ND AVE FL 33143
SOUTH MIAMI FL
33143-4701
US

IV. Provider business mailing address

7830 PINE FORK DR
ORLANDO FL
32822-7228
US

V. Phone/Fax

Practice location:
  • Phone: 305-284-7500
  • Fax:
Mailing address:
  • Phone: 407-516-5041
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: