Provider Demographics
NPI:1780358564
Name:SHAW, LAVERN VICTORIA
Entity type:Individual
Prefix:
First Name:LAVERN
Middle Name:VICTORIA
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 1:7901 NW 43RD ST
Mailing Address - Street 2:
Mailing Address - City:CORAL SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33065-1900
Mailing Address - Country:US
Mailing Address - Phone:754-702-8836
Mailing Address - Fax:754-702-2621
Practice Address - Street 1:7901 NW 43RD ST
Practice Address - Street 2:
Practice Address - City:CORAL SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:33065-1900
Practice Address - Country:US
Practice Address - Phone:754-702-8836
Practice Address - Fax:754-702-2621
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-04
Last Update Date:2021-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPN5199350164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse