Provider Demographics
NPI:1013045459
Name:SHORT, WANDA S (LPT 27571)
Entity Type:Individual
Prefix:MRS
First Name:WANDA
Middle Name:S
Last Name:SHORT
Suffix:
Gender:F
Credentials:LPT 27571
Other - Prefix:
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Mailing Address - Street 1:1965 LIVE OAK BLVD
Mailing Address - Street 2:
Mailing Address - City:YUBA CITY
Mailing Address - State:CA
Mailing Address - Zip Code:95991-8828
Mailing Address - Country:US
Mailing Address - Phone:530-822-7200
Mailing Address - Fax:530-822-3216
Practice Address - Street 1:1965 LIVE OAK BLVD
Practice Address - Street 2:
Practice Address - City:YUBA CITY
Practice Address - State:CA
Practice Address - Zip Code:95991-8828
Practice Address - Country:US
Practice Address - Phone:530-822-7200
Practice Address - Fax:530-822-3216
Is Sole Proprietor?:No
Enumeration Date:2007-02-28
Last Update Date:2011-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT27571167G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes167G00000XNursing Service ProvidersLicensed Psychiatric Technician