Provider Demographics
NPI:1467854042
Name:SHAW, KIMBERLY C (FNP-BC)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:C
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:PO BOX 1257
Mailing Address - Street 2:6500 HOSPITAL DRIVE
Mailing Address - City:HANNIBAL
Mailing Address - State:MO
Mailing Address - Zip Code:63401-1257
Mailing Address - Country:US
Mailing Address - Phone:573-406-5888
Mailing Address - Fax:573-406-5889
Practice Address - Street 1:6500 HOSPITAL DR
Practice Address - Street 2:FAMILY MEDICINE
Practice Address - City:HANNIBAL
Practice Address - State:MO
Practice Address - Zip Code:63401-6890
Practice Address - Country:US
Practice Address - Phone:573-629-3400
Practice Address - Fax:573-629-3414
Is Sole Proprietor?:No
Enumeration Date:2014-09-25
Last Update Date:2014-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO146869163W00000X
IL041359642163W00000X
MO2014037315363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse