MEDICARE: ALICE CATHERINE SHAW FNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	58326	WY
2	363LF0000X	Family Nurse Practitioner	71010179A	IN

General Provider Information

NPI Number	:	1063020279
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ALICE CATHERINE SHAW FNP

Provider Business Mailing Address
First Line	:	4440 N PORTAGE AVE
Second Line	:
City	:	SOUTH BEND
State	:	IN
Zip	:	46628
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4440 N PORTAGE AVE
Second Line	:
City	:	SOUTH BEND
State	:	IN
Zip	:	46628-9570
Country	:	US
Telephone Number	:	574-204-6200
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/14/2020
Last Update Date	:	02/26/2026

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