Provider Demographics
NPI:1124379540
Name:SHORT, DIANA
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:SHORT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2190 PHIPPS RD
Mailing Address - Street 2:
Mailing Address - City:CARSONVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48419-9259
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:227 E SANILAC RD
Practice Address - Street 2:
Practice Address - City:SANDUSKY
Practice Address - State:MI
Practice Address - Zip Code:48471-1160
Practice Address - Country:US
Practice Address - Phone:810-648-0330
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-25
Last Update Date:2012-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other