Provider Demographics
NPI:1114113214
Name:SHAW, KELLY L (RN)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:L
Last Name:SHAW
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8154 PAINTED TREE TRL
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76131-4559
Mailing Address - Country:US
Mailing Address - Phone:817-306-5604
Mailing Address - Fax:
Practice Address - Street 1:8154 PAINTED TREE TRL
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76131-4559
Practice Address - Country:US
Practice Address - Phone:817-306-5604
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-21
Last Update Date:2007-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX664845163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0400XNursing Service ProvidersRegistered NurseCase Management