Healthcare Provider Details

I. General information

NPI: 1962317412
Provider Name (Legal Business Name): HOLLY SHAW
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/18/2026
Last Update Date: 08/18/2026
Certification Date: 08/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 S HIGHLAND AVE
PLYMOUTH WI
53073-2566
US

IV. Provider business mailing address

125 S HIGHLAND AVE
PLYMOUTH WI
53073-2566
US

V. Phone/Fax

Practice location:
  • Phone: 920-892-2661
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License Number26163230
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: