Healthcare Provider Details

I. General information

NPI: 1790880961
Provider Name (Legal Business Name): ELIZABETH SHALLENBERGER NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2006
Last Update Date: 04/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1510 SAN PABL STREET
LOS ANGELES CA
90033-5320
US

IV. Provider business mailing address

PO BOX 31309
LOS ANGELES CA
90031-0309
US

V. Phone/Fax

Practice location:
  • Phone: 323-442-5907
  • Fax: 323-442-6020
Mailing address:
  • Phone: 323-865-1241
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number16796
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number213285
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: