Provider Demographics
NPI:1932490505
Name:SHAW, HEIDI LYNN (FNP)
Entity Type:Individual
Prefix:MS
First Name:HEIDI
Middle Name:LYNN
Last Name:SHAW
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1447 WAKEFEILD TERRACE
Mailing Address - Street 2:
Mailing Address - City:TITUSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32796
Mailing Address - Country:US
Mailing Address - Phone:321-268-0400
Mailing Address - Fax:
Practice Address - Street 1:2025 MURRELL ROAD
Practice Address - Street 2:
Practice Address - City:ROCKLEDGE
Practice Address - State:FL
Practice Address - Zip Code:32955
Practice Address - Country:US
Practice Address - Phone:321-735-0245
Practice Address - Fax:321-633-4449
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-29
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN3277012363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLARNP3277012OtherFL NP LICENSE
FLRN3277012OtherFL RN LICENSE
FLRN3277012OtherFL RN LICENSE