Provider Demographics
NPI:1316277593
Name:SHAW, NICOLE LEVARSETTE
Entity type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:LEVARSETTE
Last Name:SHAW
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:NICOLE
Other - Middle Name:LEVARSETTE
Other - Last Name:SIMMONS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1602 PRINCETON LN
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30904-5070
Mailing Address - Country:US
Mailing Address - Phone:706-877-3194
Mailing Address - Fax:
Practice Address - Street 1:1602 PRINCETON LN
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30904-5070
Practice Address - Country:US
Practice Address - Phone:706-877-3194
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-11
Last Update Date:2010-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA470101090265145183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician