Provider Demographics
NPI:1811364995
Name:SHAW, STEPHANIE (DNP)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:SHAW
Suffix:
Gender:F
Credentials:DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:823 RIVER RD
Mailing Address - Street 2:
Mailing Address - City:REDFIELD
Mailing Address - State:AR
Mailing Address - Zip Code:72132-9667
Mailing Address - Country:US
Mailing Address - Phone:501-397-2261
Mailing Address - Fax:501-397-2262
Practice Address - Street 1:823 RIVER RD
Practice Address - Street 2:
Practice Address - City:REDFIELD
Practice Address - State:AR
Practice Address - Zip Code:72132-9667
Practice Address - Country:US
Practice Address - Phone:501-397-2261
Practice Address - Fax:501-397-2262
Is Sole Proprietor?:No
Enumeration Date:2015-08-25
Last Update Date:2018-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA004457363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR213811758Medicaid
ARA004457OtherAPRN LICENSE