Provider Demographics
NPI:1285470534
Name:SHAW, RENA LACHELLE
Entity type:Individual
Prefix:
First Name:RENA
Middle Name:LACHELLE
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 1:55 MONUMENT CIR STE 222A
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46204-2910
Mailing Address - Country:US
Mailing Address - Phone:463-224-4397
Mailing Address - Fax:
Practice Address - Street 1:6434 E 52ND ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46226-2588
Practice Address - Country:US
Practice Address - Phone:463-224-4397
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-06
Last Update Date:2024-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier