Provider Demographics
NPI:1407059439
Name:SHAW, STACEY (NP)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:SHAW
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6705 RANGEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80918-7300
Mailing Address - Country:US
Mailing Address - Phone:719-599-7331
Mailing Address - Fax:719-390-1333
Practice Address - Street 1:6705 RANGEWOOD DR
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80918-7300
Practice Address - Country:US
Practice Address - Phone:719-599-7331
Practice Address - Fax:719-390-1333
Is Sole Proprietor?:No
Enumeration Date:2007-06-07
Last Update Date:2014-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO177117163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse