Provider Demographics
NPI:1366646788
Name:SHAW, MOLLY A (RD)
Entity Type:Individual
Prefix:MRS
First Name:MOLLY
Middle Name:A
Last Name:SHAW
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11338 34TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98125-6808
Mailing Address - Country:US
Mailing Address - Phone:206-367-9167
Mailing Address - Fax:
Practice Address - Street 1:2124 4TH AVE
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98121-2308
Practice Address - Country:US
Practice Address - Phone:206-296-4981
Practice Address - Fax:206-296-0184
Is Sole Proprietor?:No
Enumeration Date:2007-06-11
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WADI00000532Medicaid