Healthcare Provider Details

I. General information

NPI: 1093226789
Provider Name (Legal Business Name): STACEY LYNN SHAW APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/20/2017
Last Update Date: 06/15/2026
Certification Date: 06/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

607 BRIARWOOD DR STE 6
MYRTLE BEACH SC
29572-6733
US

IV. Provider business mailing address

607 BRIARWOOD DR STE 6
MYRTLE BEACH SC
29572-6733
US

V. Phone/Fax

Practice location:
  • Phone: 854-237-5617
  • Fax: 854-237-5618
Mailing address:
  • Phone: 854-237-5617
  • Fax: 854-237-5618

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number20127
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: