MEDICARE: MICHELE SHORT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	164W00000X	Licensed Practical Nurse	226031	NY

General Provider Information

NPI Number	:	1538317672
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHELE SHORT

Provider Business Mailing Address
First Line	:	7 WILLIAMS BLVD
Second Line	:	APT # 2L
City	:	LAKE GROVE
State	:	NY
Zip	:	11755-2451
Country	:	US
Telephone Number	:	631-676-6599
Fax Number	:

Provider Business Practice Location Address
First Line	:	7 WILLIAMS BLVD
Second Line	:	APT # 2L
City	:	LAKE GROVE
State	:	NY
Zip	:	11755-2451
Country	:	US
Telephone Number	:	631-676-6599
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/03/2008
Last Update Date	:	09/03/2008

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Directions to “ MICHELE SHORT ” Practice Location

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