Provider Demographics
NPI:1154728251
Name:SHORT, STEPHANIE ANN (APRN)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:ANN
Last Name:SHORT
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:ANN
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN
Mailing Address - Street 1:1907 E PITTSBURG CHURCH RD
Mailing Address - Street 2:
Mailing Address - City:LONDON
Mailing Address - State:KY
Mailing Address - Zip Code:40741-9047
Mailing Address - Country:US
Mailing Address - Phone:606-389-5269
Mailing Address - Fax:606-389-5276
Practice Address - Street 1:1907 E PITTSBURG CHURCH RD
Practice Address - Street 2:
Practice Address - City:LONDON
Practice Address - State:KY
Practice Address - Zip Code:40741-9047
Practice Address - Country:US
Practice Address - Phone:606-389-5269
Practice Address - Fax:606-389-5276
Is Sole Proprietor?:No
Enumeration Date:2014-12-04
Last Update Date:2024-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3012415363LP0808X, 363L00000X
KY1128589163WA2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WA2000XNursing Service ProvidersRegistered NurseAdministrator
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100549240Medicaid