Provider Demographics
NPI:1366969578
Name:SHALLENBERGER, LISA MARIE (MMS, PA-C)
Entity type:Individual
Prefix:MS
First Name:LISA
Middle Name:MARIE
Last Name:SHALLENBERGER
Suffix:
Gender:F
Credentials:MMS, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:859 SILVERADO CT
Mailing Address - Street 2:
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-4966
Mailing Address - Country:US
Mailing Address - Phone:786-301-2626
Mailing Address - Fax:
Practice Address - Street 1:4106 W LAKE MARY BLVD STE 205
Practice Address - Street 2:
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746-3344
Practice Address - Country:US
Practice Address - Phone:407-851-5121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-28
Last Update Date:2024-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9110578363A00000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPA9110578OtherLICENSE