Provider Demographics
NPI:1205428349
Name:SHAW, ALEXANDRA CORLEY (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:CORLEY
Last Name:SHAW
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 PENNWOOD LN
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29609-1643
Mailing Address - Country:US
Mailing Address - Phone:803-269-8685
Mailing Address - Fax:
Practice Address - Street 1:429 ROPER MOUNTAIN RD STE 901
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615-4254
Practice Address - Country:US
Practice Address - Phone:864-734-7165
Practice Address - Fax:864-203-4587
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-10
Last Update Date:2022-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC24667363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health