MEDICARE: REBECCA SHAW

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	164W00000X	Licensed Practical Nurse	PN05	OH

General Provider Information

NPI Number	:	1326392218
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	REBECCA SHAW

Provider Business Mailing Address
First Line	:	8617 STATE ROUTE 47 W
Second Line	:
City	:	DE GRAFF
State	:	OH
Zip	:	43318-9714
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	8617 STATE ROUTE 47 W
Second Line	:
City	:	DE GRAFF
State	:	OH
Zip	:	43318-9714
Country	:	US
Telephone Number	:	937-844-8030
Fax Number	:

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

Provider Enumeration Date	:	10/31/2012
Last Update Date	:	10/31/2012

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Directions to “ REBECCA SHAW ” Practice Location

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