Provider Demographics
NPI:1538723267
Name:SHAW, KATOYA NICOLE (HAIR LOSS SPECIALIST)
Entity type:Individual
Prefix:
First Name:KATOYA
Middle Name:NICOLE
Last Name:SHAW
Suffix:
Gender:F
Credentials:HAIR LOSS SPECIALIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12544 WOODSTOCK DR E
Mailing Address - Street 2:
Mailing Address - City:UPPER MARLBORO
Mailing Address - State:MD
Mailing Address - Zip Code:20772-5131
Mailing Address - Country:US
Mailing Address - Phone:240-603-7903
Mailing Address - Fax:
Practice Address - Street 1:12544 WOODSTOCK DR E
Practice Address - Street 2:
Practice Address - City:UPPER MARLBORO
Practice Address - State:MD
Practice Address - Zip Code:20772-5131
Practice Address - Country:US
Practice Address - Phone:240-603-7903
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-29
Last Update Date:2019-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCCOP50087231744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management