Provider Demographics
NPI:1790880961
Name:SHALLENBERGER, ELIZABETH (NP)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:SHALLENBERGER
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 31309
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90031-0309
Mailing Address - Country:US
Mailing Address - Phone:323-865-1241
Mailing Address - Fax:
Practice Address - Street 1:1510 SAN PABL STREET
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90033-5320
Practice Address - Country:US
Practice Address - Phone:323-442-5907
Practice Address - Fax:323-442-6020
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2015-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA16796363L00000X
MA213285363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0390071Medicaid
MANP2988OtherBLUE CROSS BLUE SHIELD
MAP22186Medicare UPIN
MANP2988OtherBLUE CROSS BLUE SHIELD
MA0390071Medicaid