Provider Demographics
NPI:1164746079
Name:SHORTER, BARBARA
Entity Type:Individual
Prefix:
First Name:BARBARA
Middle Name:
Last Name:SHORTER
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 1:450 LAKEVILLE RD
Mailing Address - Street 2:SUITE M41
Mailing Address - City:NEW HYDE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11042-1117
Mailing Address - Country:US
Mailing Address - Phone:516-734-8500
Mailing Address - Fax:516-734-8535
Practice Address - Street 1:450 LAKEVILLE RD
Practice Address - Street 2:SUITE M41
Practice Address - City:NEW HYDE PARK
Practice Address - State:NY
Practice Address - Zip Code:11042-1117
Practice Address - Country:US
Practice Address - Phone:516-734-8500
Practice Address - Fax:516-734-8535
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-22
Last Update Date:2010-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY3643222133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered