Provider Demographics
NPI:1023439098
Name:SHORT, HOLLY ANN (LPN)
Entity type:Individual
Prefix:
First Name:HOLLY
Middle Name:ANN
Last Name:SHORT
Suffix:
Gender:F
Credentials:LPN
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 244
Mailing Address - Street 2:18305 WILSON LANE
Mailing Address - City:ADAMS CENTER
Mailing Address - State:NY
Mailing Address - Zip Code:13606
Mailing Address - Country:US
Mailing Address - Phone:315-921-4459
Mailing Address - Fax:
Practice Address - Street 1:18305 WILSON LANE
Practice Address - Street 2:
Practice Address - City:ADAMS CENTER
Practice Address - State:NY
Practice Address - Zip Code:13606-0244
Practice Address - Country:US
Practice Address - Phone:315-921-4459
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-18
Last Update Date:2013-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY277611-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse