Provider Demographics
NPI:1881931137
Name:SHAW, SALLY (LAC)
Entity type:Individual
Prefix:
First Name:SALLY
Middle Name:
Last Name:SHAW
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41-051 HINALEA ST
Mailing Address - Street 2:
Mailing Address - City:WAIMANALO
Mailing Address - State:HI
Mailing Address - Zip Code:96795-1611
Mailing Address - Country:US
Mailing Address - Phone:808-772-0896
Mailing Address - Fax:
Practice Address - Street 1:401 KAMAKEE ST STE 310
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96814-4243
Practice Address - Country:US
Practice Address - Phone:808-772-0896
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-07
Last Update Date:2013-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI1050171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist