Provider Demographics
NPI:1134092075
Name:SHAW, RACHEL LAVON
Entity type:Individual
Prefix:
First Name:RACHEL
Middle Name:LAVON
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 1:348 LAKEVIEW CIR
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON
Mailing Address - State:TX
Mailing Address - Zip Code:75657-3985
Mailing Address - Country:US
Mailing Address - Phone:318-453-2941
Mailing Address - Fax:
Practice Address - Street 1:909 RIDGEBROOK RD STE 300
Practice Address - Street 2:
Practice Address - City:SPARKS
Practice Address - State:MD
Practice Address - Zip Code:21152-9477
Practice Address - Country:US
Practice Address - Phone:443-383-9300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-09-26
Last Update Date:2025-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1213153363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner