Provider Demographics
NPI:1417104415
Name:SHAW, JENNIFER LYNNE (FNP-BC)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYNNE
Last Name:SHAW
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 MARQUIS RD
Mailing Address - Street 2:
Mailing Address - City:FREEPORT
Mailing Address - State:ME
Mailing Address - Zip Code:04032-6477
Mailing Address - Country:US
Mailing Address - Phone:207-865-6131
Mailing Address - Fax:207-865-9399
Practice Address - Street 1:50 MARQUIS RD
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:ME
Practice Address - Zip Code:04032-6477
Practice Address - Country:US
Practice Address - Phone:207-865-6131
Practice Address - Fax:207-865-9399
Is Sole Proprietor?:No
Enumeration Date:2008-08-20
Last Update Date:2014-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MER046946363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily