Provider Demographics
NPI:1538764576
Name:SHAW, SHERALLA
Entity type:Individual
Prefix:MRS
First Name:SHERALLA
Middle Name:
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 1:402 CELTIC DR # 3101
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:AL
Mailing Address - Zip Code:35758-1876
Mailing Address - Country:US
Mailing Address - Phone:256-867-1000
Mailing Address - Fax:
Practice Address - Street 1:402 CELTIC DR # 3101
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:AL
Practice Address - Zip Code:35758-1876
Practice Address - Country:US
Practice Address - Phone:256-867-1000
Practice Address - Fax:256-430-9830
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-30
Last Update Date:2020-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL47B0M78343900000X
AL47D3P21343900000X
AL47B0M77343900000X
AL47B6R84343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL825424375OtherATNA, HUMANNA, MEDICAID
AL825424375Medicaid