Provider Demographics
NPI:1396441408
Name:SHAW, BROOKE JALEIGH (APRN)
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:JALEIGH
Last Name:SHAW
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5350 CLUM RD
Mailing Address - Street 2:
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45806-9246
Mailing Address - Country:US
Mailing Address - Phone:419-230-0072
Mailing Address - Fax:
Practice Address - Street 1:5350 CLUM RD
Practice Address - Street 2:
Practice Address - City:LIMA
Practice Address - State:OH
Practice Address - Zip Code:45806-9246
Practice Address - Country:US
Practice Address - Phone:419-230-0072
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-01
Last Update Date:2023-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.0033146363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily