MEDICARE: ELISE SHANKLE FNP

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	363LF0000X	Family Nurse Practitioner	AP139106	TX

General Provider Information

NPI Number	:	1114493236
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELISE SHANKLE FNP

Provider Business Mailing Address
First Line	:	2517 OPEN RANGE DR
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76177-2146
Country	:	US
Telephone Number	:	832-851-8973
Fax Number	:

Provider Business Practice Location Address
First Line	:	1921 S MAIN ST
Second Line	:
City	:	KELLER
State	:	TX
Zip	:	76248-5120
Country	:	US
Telephone Number	:	832-851-8973
Fax Number	:

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

Provider Enumeration Date	:	10/16/2018
Last Update Date	:	11/12/2019

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