Provider Demographics
NPI:1437455805
Name:SHAW, MARY (CNC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:SHAW
Suffix:
Gender:F
Credentials:CNC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2558 DARROCH CT
Mailing Address - Street 2:
Mailing Address - City:NAPA
Mailing Address - State:CA
Mailing Address - Zip Code:94558-2616
Mailing Address - Country:US
Mailing Address - Phone:707-258-0852
Mailing Address - Fax:
Practice Address - Street 1:2558 DARROCH CT
Practice Address - Street 2:
Practice Address - City:NAPA
Practice Address - State:CA
Practice Address - Zip Code:94558-2616
Practice Address - Country:US
Practice Address - Phone:707-258-0852
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-02
Last Update Date:2011-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANON REQUIRED133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist