1417139007 NPI number — MS. KIMBERLY DAWN SHAW COTA/L

Table of content: MS. KIMBERLY DAWN SHAW COTA/L (NPI 1417139007)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417139007 NPI number — MS. KIMBERLY DAWN SHAW COTA/L

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHAW
Provider First Name:
KIMBERLY
Provider Middle Name:
DAWN
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
COTA/L
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
NEWMAN
Provider Other First Name:
KIMBERLY
Provider Other Middle Name:
DAWN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
COTA/L
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1417139007
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/02/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
15413 S CR 207
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BLAIR
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
73526-9256
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
580-301-4277
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
811 E VIRGINIA AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STILLWATER
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74075-7919
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
405-377-8255
Provider Business Practice Location Address Fax Number:
405-835-3920
Provider Enumeration Date:
12/05/2007

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: 224Z00000X , with the licence number:  952 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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