Provider Demographics
NPI:1053134072
Name:SHORT, NICHOLE MARIE
Entity type:Individual
Prefix:
First Name:NICHOLE
Middle Name:MARIE
Last Name:SHORT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4343 MILL POND CIR
Mailing Address - Street 2:
Mailing Address - City:PERRY
Mailing Address - State:OH
Mailing Address - Zip Code:44081-9545
Mailing Address - Country:US
Mailing Address - Phone:440-251-5665
Mailing Address - Fax:
Practice Address - Street 1:4343 MILL POND CIR
Practice Address - Street 2:
Practice Address - City:PERRY
Practice Address - State:OH
Practice Address - Zip Code:44081-9545
Practice Address - Country:US
Practice Address - Phone:440-251-5665
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-07
Last Update Date:2024-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHF10241144363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily