MEDICARE: STACEY 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	171M00000X	Case Manager/Care Coordinator

General Provider Information

NPI Number	:	1871251447
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STACEY SHAW

Provider Business Mailing Address
First Line	:	PO BOX 5497
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53205-0497
Country	:	US
Telephone Number	:	414-578-6982
Fax Number	:

Provider Business Practice Location Address
First Line	:	2957 N 47TH ST
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53210-1731
Country	:	US
Telephone Number	:	414-578-6982
Fax Number	:

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

Provider Enumeration Date	:	12/01/2021
Last Update Date	:	12/01/2021

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Directions to “ STACEY SHAW ” Practice Location

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