Provider Demographics
NPI:1265266217
Name:SHORT, DESIREE M (APRN, FNP-C)
Entity type:Individual
Prefix:
First Name:DESIREE
Middle Name:M
Last Name:SHORT
Suffix:
Gender:F
Credentials:APRN, FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1809 S WEEKS ST
Mailing Address - Street 2:
Mailing Address - City:BONIFAY
Mailing Address - State:FL
Mailing Address - Zip Code:32425-3289
Mailing Address - Country:US
Mailing Address - Phone:850-373-3736
Mailing Address - Fax:
Practice Address - Street 1:1002 NORTH ARNOLD ROAD
Practice Address - Street 2:SUITE 102
Practice Address - City:PANAMA CITY BEACH
Practice Address - State:FL
Practice Address - Zip Code:32413
Practice Address - Country:US
Practice Address - Phone:850-234-3087
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-30
Last Update Date:2024-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11033540207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine