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General NPI Number Information
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NPI Number | 1417627589
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Entity Type | Individual
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Provider Name | NICOLE LYNN SHAW FNP
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Gender | Female
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Dates
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Enumeration Date | 09/20/2021
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Last Update Date | 11/25/2024
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Provider Practice Location Address
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Address Line | 850 S HEALTH PARKWAY
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City | THREE RIVERS
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State | MI
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Zip | 49093-8358
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Country | US
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Telephone | 269-279-5240
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Fax | 269-273-9060
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Provider Business Mailing Address
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Address Line | 3245 HEALTH DR STE 100
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City | GRANGER
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State | IN
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Zip | 46530-1380
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Country | US
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Telephone |
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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 | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 4704299077
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License Number State | MI
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