Provider Demographics
NPI:1558172973
Name:SHAW, NICOLE ANNIELL (LMT)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:ANNIELL
Last Name:SHAW
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:226 N BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:SYLACAUGA
Mailing Address - State:AL
Mailing Address - Zip Code:35150-2526
Mailing Address - Country:US
Mailing Address - Phone:716-563-8422
Mailing Address - Fax:
Practice Address - Street 1:226 N BROADWAY AVE STE 6
Practice Address - Street 2:
Practice Address - City:SYLACAUGA
Practice Address - State:AL
Practice Address - Zip Code:35150-2526
Practice Address - Country:US
Practice Address - Phone:716-563-8422
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-15
Last Update Date:2025-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL5181225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist