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General NPI Number Information
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NPI Number | 1043705346
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Entity Type | Individual
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Provider Name | CAROLINE KELLER SHAW
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Gender | Female
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Dates
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Enumeration Date | 06/28/2018
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Last Update Date | 06/28/2018
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Provider Practice Location Address
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Address Line | 16819 NE 159TH ST
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City | BRUSH PRAIRIE
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State | WA
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Zip | 98606-7323
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Country | US
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Telephone | 360-448-6450
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Fax |
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Provider Business Mailing Address
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Address Line | 230 W WINDSOR AVE
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City | ALEXANDRIA
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State | VA
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Zip | 22301-1518
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Country | US
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Telephone | 703-819-6915
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number |
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License Number State |
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