Provider Demographics
NPI:1093565236
Name:SHAW, EMMANUEL ADEYEMI (LPN)
Entity Type:Individual
Prefix:
First Name:EMMANUEL
Middle Name:ADEYEMI
Last Name:SHAW
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4230 DUNWOOD TER
Mailing Address - Street 2:
Mailing Address - City:BURTONSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20866-1322
Mailing Address - Country:US
Mailing Address - Phone:202-413-6650
Mailing Address - Fax:
Practice Address - Street 1:4230 DUNWOOD TER
Practice Address - Street 2:
Practice Address - City:BURTONSVILLE
Practice Address - State:MD
Practice Address - Zip Code:20866-1322
Practice Address - Country:US
Practice Address - Phone:202-413-6650
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-22
Last Update Date:2024-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLP48563164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse