Provider Demographics
NPI:1154630549
Name:SHORTELL, ELIZABETH M (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:M
Last Name:SHORTELL
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 NICOLLS RD
Mailing Address - Street 2:
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11794-8500
Mailing Address - Country:US
Mailing Address - Phone:631-444-1512
Mailing Address - Fax:
Practice Address - Street 1:101 NICOLLS RD
Practice Address - Street 2:HSC-T17 ROOM 040/DIVISION OD PULMONARY MEDICINE
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11794-8172
Practice Address - Country:US
Practice Address - Phone:631-444-7786
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-02
Last Update Date:2010-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY7233900363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health