Healthcare Provider Details

I. General information

NPI: 1104300094
Provider Name (Legal Business Name): ELIZABETH SHALLENBERGER APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/18/2018
Last Update Date: 09/04/2024
Certification Date: 09/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

803 N 1ST ST
VIENNA IL
62995-1544
US

IV. Provider business mailing address

1520 CEDAR GROVE RD
BUNCOMBE IL
62912-2052
US

V. Phone/Fax

Practice location:
  • Phone: 618-658-2811
  • Fax: 618-833-6267
Mailing address:
  • Phone: 618-201-5926
  • Fax: 618-833-6267

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209018052
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209018052
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: