Provider Demographics
NPI:1386307957
Name:SHULTA, ELISSA (DNP, RN)
Entity type:Individual
Prefix:
First Name:ELISSA
Middle Name:
Last Name:SHULTA
Suffix:
Gender:F
Credentials:DNP, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1130 S 101ST ST
Mailing Address - Street 2:
Mailing Address - City:WEST ALLIS
Mailing Address - State:WI
Mailing Address - Zip Code:53214-2510
Mailing Address - Country:US
Mailing Address - Phone:414-840-0325
Mailing Address - Fax:
Practice Address - Street 1:8915 W CONNELL AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-3067
Practice Address - Country:US
Practice Address - Phone:414-840-0325
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-20
Last Update Date:2021-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI229463364SX0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SX0204XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistOncology, Pediatrics