Provider Demographics
NPI:1003089905
Name:SHORT, MILISSA K (FNP-BC)
Entity Type:Individual
Prefix:
First Name:MILISSA
Middle Name:K
Last Name:SHORT
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10003 WEBSTER ROAD
Mailing Address - Street 2:CAMDEN ON GAULEY MEDICAL CENTER INC
Mailing Address - City:CAMDEN ON GAULEY
Mailing Address - State:WV
Mailing Address - Zip Code:26208-0069
Mailing Address - Country:US
Mailing Address - Phone:304-226-5725
Mailing Address - Fax:304-226-3274
Practice Address - Street 1:10003 WEBSTER ROAD
Practice Address - Street 2:
Practice Address - City:CAMDEN ON GAULEY
Practice Address - State:WV
Practice Address - Zip Code:26208-0069
Practice Address - Country:US
Practice Address - Phone:304-226-5725
Practice Address - Fax:304-226-3274
Is Sole Proprietor?:No
Enumeration Date:2008-04-11
Last Update Date:2020-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV43219363LP2300X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV43219OtherLICENSE
WV5118971Medicare PIN
WVD518361Medicare PIN
WV43219OtherLICENSE
WV511897Medicare Oscar/Certification
WV5118271Medicare PIN