MEDICARE: KRYSTLE CASH-SHAW NP-C

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	208051	LA

General Provider Information

NPI Number	:	1285284612
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KRYSTLE CASH-SHAW NP-C

Provider Business Mailing Address
First Line	:	447 BETHANY CHURCH RD
Second Line	:
City	:	QUITMAN
State	:	LA
Zip	:	71268-1025
Country	:	US
Telephone Number	:	318-243-1904
Fax Number	:

Provider Business Practice Location Address
First Line	:	1640 BREAZEALE SPRINGS ST
Second Line	:
City	:	NATCHITOCHES
State	:	LA
Zip	:	71457-4278
Country	:	US
Telephone Number	:	318-352-9299
Fax Number	:

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

Provider Enumeration Date	:	09/17/2019
Last Update Date	:	09/17/2019

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