Provider Demographics
NPI:1134380587
Name:SHAW, JOHNELLE NUSPL (PT, MSPT, DPT)
Entity type:Individual
Prefix:
First Name:JOHNELLE
Middle Name:NUSPL
Last Name:SHAW
Suffix:
Gender:F
Credentials:PT, MSPT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1021 STAGECOACH DR
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:CO
Mailing Address - Zip Code:80026-8703
Mailing Address - Country:US
Mailing Address - Phone:303-514-9912
Mailing Address - Fax:
Practice Address - Street 1:1021 STAGECOACH DR
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:CO
Practice Address - Zip Code:80026-8703
Practice Address - Country:US
Practice Address - Phone:303-514-9912
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-18
Last Update Date:2020-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO8650171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO33972273Medicaid