Provider Demographics
NPI:1598005027
Name:SHORT, SANDRA L (ANP-BC)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:L
Last Name:SHORT
Suffix:
Gender:F
Credentials:ANP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:496 SOUTHLAND DR
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40503-1827
Mailing Address - Country:US
Mailing Address - Phone:859-288-2392
Mailing Address - Fax:859-721-3918
Practice Address - Street 1:360 W LOUDON AVE
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40508
Practice Address - Country:US
Practice Address - Phone:859-388-9033
Practice Address - Fax:859-721-3918
Is Sole Proprietor?:No
Enumeration Date:2013-02-20
Last Update Date:2019-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3007737363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100247640Medicaid