Provider Demographics
NPI:1174219638
Name:SHAW, CHAVONNE NAKIA
Entity type:Individual
Prefix:
First Name:CHAVONNE
Middle Name:NAKIA
Last Name:SHAW
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:537 BELLGROVE DR
Mailing Address - Street 2:
Mailing Address - City:HOPE MILLS
Mailing Address - State:NC
Mailing Address - Zip Code:28348-2795
Mailing Address - Country:US
Mailing Address - Phone:843-425-4507
Mailing Address - Fax:
Practice Address - Street 1:1357 WALTER REED RD STE 101
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-4417
Practice Address - Country:US
Practice Address - Phone:910-984-8311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-17
Last Update Date:2023-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5017965363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner