Provider Demographics
NPI:1326667874
Name:SHORT, NICOLE BREANN
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:BREANN
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 1:1813 RIVER RD
Mailing Address - Street 2:
Mailing Address - City:ROYALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62983
Mailing Address - Country:US
Mailing Address - Phone:618-925-1040
Mailing Address - Fax:
Practice Address - Street 1:1813 RIVER RD
Practice Address - Street 2:
Practice Address - City:ROYALTON
Practice Address - State:IL
Practice Address - Zip Code:62983
Practice Address - Country:US
Practice Address - Phone:618-925-1040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-15
Last Update Date:2020-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program