Provider Demographics
NPI:1104600691
Name:CARBULLIDO, SHIELAMAE N (A-GNP-C)
Entity type:Individual
Prefix:
First Name:SHIELAMAE
Middle Name:N
Last Name:CARBULLIDO
Suffix:
Gender:F
Credentials:A-GNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1246 JESTER CT
Mailing Address - Street 2:
Mailing Address - City:COPPERAS COVE
Mailing Address - State:TX
Mailing Address - Zip Code:76522-8102
Mailing Address - Country:US
Mailing Address - Phone:254-981-6072
Mailing Address - Fax:
Practice Address - Street 1:3035 STILLHOUSE LAKE RD,
Practice Address - Street 2:
Practice Address - City:HARKER HEIGHTS
Practice Address - State:TX
Practice Address - Zip Code:76548
Practice Address - Country:US
Practice Address - Phone:254-519-8922
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-24
Last Update Date:2023-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1129827363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care