=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457701005
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NICOLE M SHAW DPT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/14/2016
-----------------------------------------------------
Last Update Date | 06/14/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3100 COLONY DR
-----------------------------------------------------
City | ALLIANCE
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44601-5244
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-374-1780
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3100 COLONY DR
-----------------------------------------------------
City | ALLIANCE
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44601-5244
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-374-1780
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | PT013837
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------