Provider Demographics
NPI:1659645273
Name:SHORT, TERESA L (FNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:TERESA
Middle Name:L
Last Name:SHORT
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:203 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:IN
Mailing Address - Zip Code:47374-4208
Mailing Address - Country:US
Mailing Address - Phone:765-973-9294
Mailing Address - Fax:765-973-9233
Practice Address - Street 1:1250 CHESTER BLVD
Practice Address - Street 2:SUITE 2
Practice Address - City:RICHMOND
Practice Address - State:IN
Practice Address - Zip Code:47374-1933
Practice Address - Country:US
Practice Address - Phone:765-935-8581
Practice Address - Fax:765-935-1171
Is Sole Proprietor?:No
Enumeration Date:2012-02-29
Last Update Date:2024-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71003919A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201057160Medicaid
000000757297OtherANTHEM (BCBS)
000000757297OtherANTHEM (BCBS)
IN201057160Medicaid