Provider Demographics
NPI:1740878545
Name:SHORT, KIMBERLY (CRNP)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:SHORT
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:806 ELLIS AVE
Mailing Address - Street 2:
Mailing Address - City:NEWTOWN SQUARE
Mailing Address - State:PA
Mailing Address - Zip Code:19073-3906
Mailing Address - Country:US
Mailing Address - Phone:610-772-1911
Mailing Address - Fax:
Practice Address - Street 1:806 ELLIS AVE
Practice Address - Street 2:
Practice Address - City:NEWTOWN SQUARE
Practice Address - State:PA
Practice Address - Zip Code:19073-3906
Practice Address - Country:US
Practice Address - Phone:610-772-1911
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-06
Last Update Date:2021-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN529138L363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
PASP023469OtherBOARD OF NURSING