Provider Demographics
NPI:1932177961
Name:SHORT, KELLI J (FNP)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:J
Last Name:SHORT
Suffix:
Gender:F
Credentials:FNP
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 172
Mailing Address - Street 2:
Mailing Address - City:LOHN
Mailing Address - State:TX
Mailing Address - Zip Code:76852-0172
Mailing Address - Country:US
Mailing Address - Phone:325-344-5566
Mailing Address - Fax:
Practice Address - Street 1:551 EAKER STREET
Practice Address - Street 2:
Practice Address - City:EDEN
Practice Address - State:TX
Practice Address - Zip Code:76837-0989
Practice Address - Country:US
Practice Address - Phone:325-869-8811
Practice Address - Fax:325-869-8899
Is Sole Proprietor?:No
Enumeration Date:2006-03-08
Last Update Date:2011-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX629727363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
8D3594Medicare ID - Type Unspecified
TX00650RMedicare Oscar/Certification
TX8A4659Medicare UPIN
P36763Medicare UPIN
TX451325Medicare Oscar/Certification