Provider Demographics
NPI:1558609099
Name:SHORT, KATE L (NP)
Entity Type:Individual
Prefix:
First Name:KATE
Middle Name:L
Last Name:SHORT
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 677
Mailing Address - Street 2:
Mailing Address - City:SCOTTSBURG
Mailing Address - State:IN
Mailing Address - Zip Code:47170-0677
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2502 25TH ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:IN
Practice Address - Zip Code:47201-3728
Practice Address - Country:US
Practice Address - Phone:812-372-8883
Practice Address - Fax:812-372-8964
Is Sole Proprietor?:No
Enumeration Date:2013-01-17
Last Update Date:2020-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71004236A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201150620Medicaid
IN000000991689OtherANTHEM PIN
IN000000991689OtherANTHEM PIN