Provider Demographics
NPI:1336664655
Name:SHORTLE, JOHANNAH
Entity Type:Individual
Prefix:
First Name:JOHANNAH
Middle Name:
Last Name:SHORTLE
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 1:651 RIDGE RD APT B4
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:NY
Mailing Address - Zip Code:14882-8866
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4435 SENECA RD
Practice Address - Street 2:
Practice Address - City:TRUMANSBURG
Practice Address - State:NY
Practice Address - Zip Code:14886-9201
Practice Address - Country:US
Practice Address - Phone:607-387-5707
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-08
Last Update Date:2017-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY341858363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner