Provider Demographics
NPI:1376298760
Name:SHORT, SOPHIA (MA, CNA)
Entity Type:Individual
Prefix:
First Name:SOPHIA
Middle Name:
Last Name:SHORT
Suffix:
Gender:F
Credentials:MA, CNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9401 W BELOIT RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53227-4357
Mailing Address - Country:US
Mailing Address - Phone:414-301-3141
Mailing Address - Fax:
Practice Address - Street 1:9401 W BELOIT RD
Practice Address - Street 2:SUITE 101
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53227-4357
Practice Address - Country:US
Practice Address - Phone:414-301-3141
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-15
Last Update Date:2022-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI871839143Medicaid