Provider Demographics
NPI:1962017921
Name:SHAW, LEAH ANN (RDN,LD)
Entity Type:Individual
Prefix:MS
First Name:LEAH
Middle Name:ANN
Last Name:SHAW
Suffix:
Gender:F
Credentials:RDN,LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2211 HIGH COUNTRY DR
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:TX
Mailing Address - Zip Code:75007-1701
Mailing Address - Country:US
Mailing Address - Phone:214-673-8632
Mailing Address - Fax:
Practice Address - Street 1:2211 HIGH COUNTRY DR
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:TX
Practice Address - Zip Code:75007-1701
Practice Address - Country:US
Practice Address - Phone:214-673-8632
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-15
Last Update Date:2020-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX807607133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX13343654Medicaid