Provider Demographics
NPI:1386776243
Name:SHAW, BROOKE A (BA, CLC)
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:A
Last Name:SHAW
Suffix:
Gender:F
Credentials:BA, CLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 510384
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63151-0384
Mailing Address - Country:US
Mailing Address - Phone:314-714-4137
Mailing Address - Fax:
Practice Address - Street 1:10030 MANCHESTER RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63122-1832
Practice Address - Country:US
Practice Address - Phone:314-714-4137
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-09
Last Update Date:2012-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374J00000XNursing Service Related ProvidersDoula
No174N00000XOther Service ProvidersLactation Consultant, Non-RN