Provider Demographics
NPI:1154297224
Name:SHORT, CASONDRA
Entity type:Individual
Prefix:
First Name:CASONDRA
Middle Name:
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 1:3490 N FOREST PARK ST
Mailing Address - Street 2:
Mailing Address - City:DERBY
Mailing Address - State:KS
Mailing Address - Zip Code:67037-4216
Mailing Address - Country:US
Mailing Address - Phone:316-706-6750
Mailing Address - Fax:
Practice Address - Street 1:3490 N FOREST PARK ST
Practice Address - Street 2:
Practice Address - City:DERBY
Practice Address - State:KS
Practice Address - Zip Code:67037-4216
Practice Address - Country:US
Practice Address - Phone:316-706-6750
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-10-15
Last Update Date:2025-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS13-135930-081163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse