Provider Demographics
NPI:1003405739
Name:SHAW, REBECCA ANNE (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:ANNE
Last Name:SHAW
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:16620 N 40TH ST STE E1
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85032-3357
Mailing Address - Country:US
Mailing Address - Phone:602-464-9576
Mailing Address - Fax:480-428-0475
Practice Address - Street 1:16620 N 40TH ST STE E1
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85032-3357
Practice Address - Country:US
Practice Address - Phone:602-464-9576
Practice Address - Fax:480-428-0475
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-17
Last Update Date:2024-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ262350363LP0808X
AZRN171736163WA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WA0400XNursing Service ProvidersRegistered NurseAddiction (Substance Use Disorder)