Basic Information
| Provider Information | |||||||||
| NPI: | 1114038320 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHAW | ||||||||
| FirstName: | FONDA | ||||||||
| MiddleName: | KAY | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | FNP/CNM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1378 EAGLE LN | ||||||||
| Address2: | |||||||||
| City: | OLIVEHURST | ||||||||
| State: | CA | ||||||||
| PostalCode: | 959619680 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5307421138 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1908 N BEALE RD | ||||||||
| Address2: | STE. E | ||||||||
| City: | MARYSVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 959016937 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5307436888 | ||||||||
| FaxNumber: | 5307439823 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2006 | ||||||||
| LastUpdateDate: | 08/19/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 12989NP | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 367A00000X | 1854 | CA | N | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife |
No ID Information.