Provider Demographics
NPI:1538317672
Name:SHORT, MICHELE
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:
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 1:7 WILLIAMS BLVD
Mailing Address - Street 2:APT # 2L
Mailing Address - City:LAKE GROVE
Mailing Address - State:NY
Mailing Address - Zip Code:11755-2451
Mailing Address - Country:US
Mailing Address - Phone:631-676-6599
Mailing Address - Fax:
Practice Address - Street 1:7 WILLIAMS BLVD
Practice Address - Street 2:APT # 2L
Practice Address - City:LAKE GROVE
Practice Address - State:NY
Practice Address - Zip Code:11755-2451
Practice Address - Country:US
Practice Address - Phone:631-676-6599
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-03
Last Update Date:2008-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY226031164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse