Provider Demographics
NPI:1629188818
Name:SHULLANBERGER, GINGER (NP)
Entity Type:Individual
Prefix:
First Name:GINGER
Middle Name:
Last Name:SHULLANBERGER
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:PO BOX 10069
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92423-0069
Mailing Address - Country:US
Mailing Address - Phone:909-335-4188
Mailing Address - Fax:
Practice Address - Street 1:245 TERRACINA BLVD
Practice Address - Street 2:
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92373-4852
Practice Address - Country:US
Practice Address - Phone:909-793-3311
Practice Address - Fax:909-335-4105
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2020-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP128129363L00000X
IL209001147363L00000X
CA95007553363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILNON-PARTICIPATINGMedicaid
ILQ03404Medicare UPIN
ILK16937Medicare PIN