Provider Demographics
NPI:1821639246
Name:SHAW, CAROLYN SUSAN
Entity Type:Individual
Prefix:MRS
First Name:CAROLYN
Middle Name:SUSAN
Last Name:SHAW
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13312 RANCHERO RD #533
Mailing Address - Street 2:
Mailing Address - City:OAK HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:92344
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:13312 RANCHERO RD #533
Practice Address - Street 2:
Practice Address - City:OAK HILLS
Practice Address - State:CA
Practice Address - Zip Code:92344
Practice Address - Country:US
Practice Address - Phone:909-307-5248
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-07
Last Update Date:2019-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider