Provider Demographics
NPI:1184171639
Name:SHAW, SUZETT SIMONE (APN)
Entity type:Individual
Prefix:MISS
First Name:SUZETT
Middle Name:SIMONE
Last Name:SHAW
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2445 SOUTH DELSEA DRIVE
Mailing Address - Street 2:INSPIRA LIFE VINELAND
Mailing Address - City:VINELAND
Mailing Address - State:NJ
Mailing Address - Zip Code:08360
Mailing Address - Country:US
Mailing Address - Phone:856-334-1961
Mailing Address - Fax:
Practice Address - Street 1:2445 S DELSEA DR
Practice Address - Street 2:INSPIRA LIFE VINELAND
Practice Address - City:VINELAND
Practice Address - State:NJ
Practice Address - Zip Code:08360-7000
Practice Address - Country:US
Practice Address - Phone:856-334-1961
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-01
Last Update Date:2023-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00645900363LG0600X, 363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0760081Medicaid