=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205408267
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHARON MELISSA SHAW NP-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/10/2021
-----------------------------------------------------
Last Update Date | 07/10/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 72 PEACEFUL VALLEY DR
-----------------------------------------------------
City | CLEVELAND
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30528-4247
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-313-1023
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 2031
-----------------------------------------------------
City | CLEVELAND
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30528-0037
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-313-1023
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LA2200X
-----------------------------------------------------
Taxonomy Name | Adult Health Nurse Practitioner
-----------------------------------------------------
License Number | RN249693
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Nurse Practitioner
-----------------------------------------------------
License Number | RN249693
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 363LG0600X
-----------------------------------------------------
Taxonomy Name | Gerontology Nurse Practitioner
-----------------------------------------------------
License Number | RN249693
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------