Provider Demographics
NPI:1356618912
Name:SHAW, KELLEY C (CPNP)
Entity type:Individual
Prefix:MRS
First Name:KELLEY
Middle Name:C
Last Name:SHAW
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:3400A OLD MILTON PKWY STE 330
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30005-4438
Mailing Address - Country:US
Mailing Address - Phone:770-751-6111
Mailing Address - Fax:770-772-6099
Practice Address - Street 1:3400A OLD MILTON PKWY STE 330
Practice Address - Street 2:
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30005-4438
Practice Address - Country:US
Practice Address - Phone:770-751-6111
Practice Address - Fax:770-772-6099
Is Sole Proprietor?:No
Enumeration Date:2011-11-28
Last Update Date:2011-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN171700363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner