Provider Demographics
NPI:1083807606
Name:GALLIVAN, SHELLEY (NP)
Entity Type:Individual
Prefix:
First Name:SHELLEY
Middle Name:
Last Name:GALLIVAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1503 GRANT RD STE 110
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN VIEW
Mailing Address - State:CA
Mailing Address - Zip Code:94040-3270
Mailing Address - Country:US
Mailing Address - Phone:650-484-1213
Mailing Address - Fax:
Practice Address - Street 1:1503 GRANT RD STE 110
Practice Address - Street 2:
Practice Address - City:MOUNTAIN VIEW
Practice Address - State:CA
Practice Address - Zip Code:94040-3270
Practice Address - Country:US
Practice Address - Phone:650-484-1213
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-27
Last Update Date:2022-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA17816363LN0000X, 363LP0808X
IL041328453363LN0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL041-328453OtherRN LICENSE
IL209-005987OtherAPN LICENSE