Provider Demographics
NPI:1063020279
Name:SHAW, ALICE CATHERINE (FNP)
Entity Type:Individual
Prefix:
First Name:ALICE
Middle Name:CATHERINE
Last Name:SHAW
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4440 N PORTAGE AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46628
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4440 N PORTAGE AVE
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46628-9570
Practice Address - Country:US
Practice Address - Phone:574-204-6200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-14
Last Update Date:2023-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71010179A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily