Provider Demographics
NPI:1174286736
Name:SHAW, ANDREA LYN
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:LYN
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 1:900 W RACE ST
Mailing Address - Street 2:
Mailing Address - City:RIDGWAY
Mailing Address - State:IL
Mailing Address - Zip Code:62979-1150
Mailing Address - Country:US
Mailing Address - Phone:618-272-8831
Mailing Address - Fax:618-272-7118
Practice Address - Street 1:900 W RACE ST
Practice Address - Street 2:
Practice Address - City:RIDGWAY
Practice Address - State:IL
Practice Address - Zip Code:62979-1150
Practice Address - Country:US
Practice Address - Phone:618-272-8831
Practice Address - Fax:618-272-7118
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-20
Last Update Date:2021-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL043119608164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse