Provider Demographics
NPI:1528601242
Name:SHORT, FAYE LYNETTE
Entity Type:Individual
Prefix:
First Name:FAYE
Middle Name:LYNETTE
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 1:112 S 3RD ST
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:OH
Mailing Address - Zip Code:43055-5335
Mailing Address - Country:US
Mailing Address - Phone:330-556-8024
Mailing Address - Fax:
Practice Address - Street 1:112 S 3RD ST
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:OH
Practice Address - Zip Code:43055-5335
Practice Address - Country:US
Practice Address - Phone:330-556-8024
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-25
Last Update Date:2019-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator