Provider Demographics
NPI:1427876069
Name:SHAW, SAMANTHA LATOYA
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:LATOYA
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 1:357 SW LOG DR
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34953-7501
Mailing Address - Country:US
Mailing Address - Phone:772-274-3320
Mailing Address - Fax:
Practice Address - Street 1:357 SW LOG DR
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34953-7501
Practice Address - Country:US
Practice Address - Phone:772-274-3320
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-02
Last Update Date:2024-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332U00000X
FL238034332U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332U00000XSuppliersHome Delivered Meals