MEDICARE: KELLY L SHAW RN

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	163WC0400X	Case Management Registered Nurse	664845	TX

General Provider Information

NPI Number	:	1114113214
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY L SHAW RN

Provider Business Mailing Address
First Line	:	8154 PAINTED TREE TRL
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76131-4559
Country	:	US
Telephone Number	:	817-306-5604
Fax Number	:

Provider Business Practice Location Address
First Line	:	8154 PAINTED TREE TRL
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76131-4559
Country	:	US
Telephone Number	:	817-306-5604
Fax Number	:

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

Provider Enumeration Date	:	09/21/2007
Last Update Date	:	09/21/2007

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