Provider Demographics
NPI:1417627589
Name:SHAW, NICOLE LYNN (FNP)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:LYNN
Last Name:SHAW
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:LYNN
Other - Last Name:SHAW
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:FNP
Mailing Address - Street 1:3245 HEALTH DR STE 100
Mailing Address - Street 2:
Mailing Address - City:GRANGER
Mailing Address - State:IN
Mailing Address - Zip Code:46530-1380
Mailing Address - Country:US
Mailing Address - Phone:574-647-1088
Mailing Address - Fax:
Practice Address - Street 1:721 6TH AVE STE A
Practice Address - Street 2:
Practice Address - City:THREE RIVERS
Practice Address - State:MI
Practice Address - Zip Code:49093-8378
Practice Address - Country:US
Practice Address - Phone:269-273-9782
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-20
Last Update Date:2023-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704299077363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1417627589Medicaid