Provider Demographics
NPI:1629641899
Name:SHORTER, BERNICE BATRICE
Entity Type:Individual
Prefix:
First Name:BERNICE
Middle Name:BATRICE
Last Name:SHORTER
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 1:2410 GOOD HOPE RD SE APT T3
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20020-3480
Mailing Address - Country:US
Mailing Address - Phone:202-819-1537
Mailing Address - Fax:
Practice Address - Street 1:1710 7THST NW
Practice Address - Street 2:APARTMENT 38
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20001
Practice Address - Country:US
Practice Address - Phone:202-609-4239
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-23
Last Update Date:2021-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC4322739163WH0200X
374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
No163WH0200XNursing Service ProvidersRegistered NurseHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC1191361Medicaid