Provider Demographics
NPI:1316431679
Name:SCOTT, SHADOW
Entity type:Individual
Prefix:
First Name:SHADOW
Middle Name:
Last Name:SCOTT
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 1:5238 OLD ISRAEL RD
Mailing Address - Street 2:
Mailing Address - City:LIVINGSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77351-1686
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5238 OLD ISRAEL RD
Practice Address - Street 2:
Practice Address - City:LIVINGSTON
Practice Address - State:TX
Practice Address - Zip Code:77351-1686
Practice Address - Country:US
Practice Address - Phone:936-252-0951
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-20
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX340091164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse