MEDICARE: KELLI J SHORT FNP

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	363LF0000X	Family Nurse Practitioner	629727	TX

General Provider Information

NPI Number	:	1932177961
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLI J SHORT FNP

Provider Business Mailing Address
First Line	:	PO BOX 172
Second Line	:
City	:	LOHN
State	:	TX
Zip	:	76852-0172
Country	:	US
Telephone Number	:	325-344-5566
Fax Number	:

Provider Business Practice Location Address
First Line	:	551 EAKER STREET
Second Line	:
City	:	EDEN
State	:	TX
Zip	:	76837-0989
Country	:	US
Telephone Number	:	325-869-8811
Fax Number	:	325-869-8899

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

Provider Enumeration Date	:	03/08/2006
Last Update Date	:	11/15/2011

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