Provider Demographics
NPI:1578800264
Name:SHORT, IDEIA P
Entity Type:Individual
Prefix:
First Name:IDEIA
Middle Name:P
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 1:1875 SAVANNAH PL SE
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20020-2103
Mailing Address - Country:US
Mailing Address - Phone:301-747-5622
Mailing Address - Fax:
Practice Address - Street 1:1875 SAVANNAH PL SE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20020-2103
Practice Address - Country:US
Practice Address - Phone:301-747-5622
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-15
Last Update Date:2013-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide