Provider Demographics
NPI:1104300094
Name:SHALLENBERGER, ELIZABETH (APRN)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:SHALLENBERGER
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1520 CEDAR GROVE RD
Mailing Address - Street 2:
Mailing Address - City:BUNCOMBE
Mailing Address - State:IL
Mailing Address - Zip Code:62912-2052
Mailing Address - Country:US
Mailing Address - Phone:618-201-5926
Mailing Address - Fax:618-833-6267
Practice Address - Street 1:803 N 1ST ST
Practice Address - Street 2:
Practice Address - City:VIENNA
Practice Address - State:IL
Practice Address - Zip Code:62995-1544
Practice Address - Country:US
Practice Address - Phone:618-658-2811
Practice Address - Fax:618-833-6267
Is Sole Proprietor?:No
Enumeration Date:2018-09-18
Last Update Date:2024-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209018052363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily