Provider Demographics
NPI:1710275680
Name:SHAW, SANDRA KAYE (CNP)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:KAYE
Last Name:SHAW
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:733 MARKET AVE S
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44702-2165
Mailing Address - Country:US
Mailing Address - Phone:330-687-8589
Mailing Address - Fax:
Practice Address - Street 1:733 MARKET AVE S
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44702-2165
Practice Address - Country:US
Practice Address - Phone:330-687-8589
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-13
Last Update Date:2015-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOA12432NP363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health