Provider Demographics
NPI:1457671265
Name:SHORT, ANGELA STALLARD (FNP)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:STALLARD
Last Name:SHORT
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:ANGELA
Other - Middle Name:L
Other - Last Name:SHORT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:FNP
Mailing Address - Street 1:PO BOX 5127
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37602-5127
Mailing Address - Country:US
Mailing Address - Phone:866-397-1439
Mailing Address - Fax:423-431-5724
Practice Address - Street 1:716 SPRING STREET
Practice Address - Street 2:
Practice Address - City:WISE
Practice Address - State:VA
Practice Address - Zip Code:24293
Practice Address - Country:US
Practice Address - Phone:276-328-8910
Practice Address - Fax:276-328-4318
Is Sole Proprietor?:No
Enumeration Date:2010-06-03
Last Update Date:2010-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024168816363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily