Provider Demographics
NPI:1114038320
Name:SHAW, FONDA KAY (FNP/CNM)
Entity Type:Individual
Prefix:MRS
First Name:FONDA
Middle Name:KAY
Last Name:SHAW
Suffix:
Gender:F
Credentials:FNP/CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1378 EAGLE LN
Mailing Address - Street 2:
Mailing Address - City:OLIVEHURST
Mailing Address - State:CA
Mailing Address - Zip Code:95961-9680
Mailing Address - Country:US
Mailing Address - Phone:530-742-1138
Mailing Address - Fax:
Practice Address - Street 1:1908 N BEALE RD
Practice Address - Street 2:STE. E
Practice Address - City:MARYSVILLE
Practice Address - State:CA
Practice Address - Zip Code:95901-6937
Practice Address - Country:US
Practice Address - Phone:530-743-6888
Practice Address - Fax:530-743-9823
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2009-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12989NP363L00000X
CA1854367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife