Provider Demographics
NPI:1942573001
Name:SHALLENBERGER, MACKENZIE (PA)
Entity Type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:
Last Name:SHALLENBERGER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2650 WARRENVILLE RD
Mailing Address - Street 2:STE. 280
Mailing Address - City:DOWNERS GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60515-1748
Mailing Address - Country:US
Mailing Address - Phone:630-324-7900
Mailing Address - Fax:
Practice Address - Street 1:640 W WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:PITTSFIELD
Practice Address - State:IL
Practice Address - Zip Code:62363-1350
Practice Address - Country:US
Practice Address - Phone:217-285-2113
Practice Address - Fax:217-277-3960
Is Sole Proprietor?:No
Enumeration Date:2012-02-20
Last Update Date:2023-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085-004155363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1101093OtherNCCPA