Provider Demographics
NPI:1760267785
Name:SHAW, DOMINIQUE NICOLE (WHNP-BC)
Entity Type:Individual
Prefix:MS
First Name:DOMINIQUE
Middle Name:NICOLE
Last Name:SHAW
Suffix:
Gender:F
Credentials:WHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13909 FLOYD ST
Mailing Address - Street 2:
Mailing Address - City:UPPER MARLBORO
Mailing Address - State:MD
Mailing Address - Zip Code:20772-6844
Mailing Address - Country:US
Mailing Address - Phone:240-274-4692
Mailing Address - Fax:
Practice Address - Street 1:26005 RIDGE RD STE 200
Practice Address - Street 2:
Practice Address - City:DAMASCUS
Practice Address - State:MD
Practice Address - Zip Code:20872-1899
Practice Address - Country:US
Practice Address - Phone:301-414-2300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-28
Last Update Date:2023-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR224771363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health