Healthcare Provider Details

I. General information

NPI: 1366354474
Provider Name (Legal Business Name): KENYA SHAW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/22/2026
Last Update Date: 09/22/2026
Certification Date: 09/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 IVY CT
RESERVE LA
70084-5505
US

IV. Provider business mailing address

104 IVY CT
RESERVE LA
70084-5505
US

V. Phone/Fax

Practice location:
  • Phone: 504-577-4331
  • Fax: 504-814-8055
Mailing address:
  • Phone: 504-577-4331
  • Fax: 504-814-8055

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174200000X
TaxonomyMeals Provider
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: