Provider Demographics
NPI:1134609266
Name:SHAW, AMY L
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:L
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 1:909 E STATE BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46805-3458
Mailing Address - Country:US
Mailing Address - Phone:260-482-9125
Mailing Address - Fax:
Practice Address - Street 1:809 HIGH ST
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IN
Practice Address - Zip Code:46733-2324
Practice Address - Country:US
Practice Address - Phone:260-724-9669
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-17
Last Update Date:2018-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator