Provider Demographics
NPI:1295080307
Name:SHAW-MCMINN, NELLY (DPT)
Entity type:Individual
Prefix:
First Name:NELLY
Middle Name:
Last Name:SHAW-MCMINN
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12171 WORLD TRADE DR
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92128-3709
Mailing Address - Country:US
Mailing Address - Phone:858-217-2137
Mailing Address - Fax:
Practice Address - Street 1:12171 WORLD TRADE DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92128-3709
Practice Address - Country:US
Practice Address - Phone:858-217-2137
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-16
Last Update Date:2012-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA39088225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist