1033419361 NPI number — MRS. LATONYA DENISE SHAW M.S

Table of content: MRS. LATONYA DENISE SHAW M.S (NPI 1033419361)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033419361 NPI number — MRS. LATONYA DENISE SHAW M.S

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHAW
Provider First Name:
LATONYA
Provider Middle Name:
DENISE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
M.S
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
LEWIS
Provider Other First Name:
LATONYA
Provider Other Middle Name:
DENISE
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.S
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1033419361
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/02/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 881147
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORT ST LUCIE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34988-1147
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
561-294-5888
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
405 SEAFOAM CIR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT PIERCE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34945-1203
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
561-294-5888
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/03/2010

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 104100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YM0800X , with the licence number: MH22407 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 119057200 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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