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General NPI Number Information
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NPI Number | 1467314419
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Entity Type | Individual
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Provider Name | BERNICE SHAW
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Gender | Female
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Dates
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Enumeration Date | 11/28/2025
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Last Update Date | 11/28/2025
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Provider Practice Location Address
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Address Line | 1916 CHERRY GLEN DR 1916 CHERRY GLEN DRIVE
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City | LA GRANGE
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State | KY
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Zip | 40031-6967
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Country | US
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Telephone | 954-940-8205
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Fax |
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Provider Business Mailing Address
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Address Line | 1916 CHERRY GLEN DR
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City | LA GRANGE
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State | KY
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Zip | 40031-6967
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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 | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number |
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License Number State |
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