Provider Demographics
NPI:1306375761
Name:SHAW, VICTORIA NICOLE
Entity Type:Individual
Prefix:MRS
First Name:VICTORIA
Middle Name:NICOLE
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 1:101 E REDLANDS BLVD STE 215
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373-4724
Mailing Address - Country:US
Mailing Address - Phone:909-793-1078
Mailing Address - Fax:909-335-7330
Practice Address - Street 1:101 E. REDLANDS BLVD. SUITE 215
Practice Address - Street 2:
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92373
Practice Address - Country:US
Practice Address - Phone:909-793-1078
Practice Address - Fax:909-335-7330
Is Sole Proprietor?:No
Enumeration Date:2017-06-08
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator