Provider Demographics
NPI:1043705346
Name:SHAW, CAROLINE KELLER
Entity Type:Individual
Prefix:
First Name:CAROLINE
Middle Name:KELLER
Last Name:SHAW
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:230 W WINDSOR AVE
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22301-1518
Mailing Address - Country:US
Mailing Address - Phone:703-819-6915
Mailing Address - Fax:
Practice Address - Street 1:16819 NE 159TH ST
Practice Address - Street 2:
Practice Address - City:BRUSH PRAIRIE
Practice Address - State:WA
Practice Address - Zip Code:98606-7323
Practice Address - Country:US
Practice Address - Phone:360-448-6450
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-28
Last Update Date:2018-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer