Provider Demographics
NPI:1093226789
Name:SHAW, STACEY LYNN (APRN)
Entity Type:Individual
Prefix:MS
First Name:STACEY
Middle Name:LYNN
Last Name:SHAW
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:286 JUNCO CIR
Mailing Address - Street 2:
Mailing Address - City:LONGS
Mailing Address - State:SC
Mailing Address - Zip Code:29568-6965
Mailing Address - Country:US
Mailing Address - Phone:843-321-5099
Mailing Address - Fax:
Practice Address - Street 1:2423 HIGHWAY 17 S
Practice Address - Street 2:
Practice Address - City:NORTH MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29582-4343
Practice Address - Country:US
Practice Address - Phone:843-919-0700
Practice Address - Fax:843-919-0727
Is Sole Proprietor?:No
Enumeration Date:2017-10-20
Last Update Date:2023-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC20127363LP0808X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health