MEDICARE: SHIELAMAE N. CARBULLIDO A-GNP-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP2300X	Primary Care Nurse Practitioner	1129827	TX

General Provider Information

NPI Number	:	1104600691
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHIELAMAE N. CARBULLIDO A-GNP-C

Provider Business Mailing Address
First Line	:	1246 JESTER CT
Second Line	:
City	:	COPPERAS COVE
State	:	TX
Zip	:	76522-8102
Country	:	US
Telephone Number	:	254-981-6072
Fax Number	:

Provider Business Practice Location Address
First Line	:	3035 STILLHOUSE LAKE RD,
Second Line	:
City	:	HARKER HEIGHTS
State	:	TX
Zip	:	76548
Country	:	US
Telephone Number	:	254-519-8922
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/24/2023
Last Update Date	:	08/24/2023

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