Healthcare Provider Details

I. General information

NPI: 1295706182
Provider Name (Legal Business Name): THEODORA L SHORT ADVANCED PRACTICE NU
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/30/2006
Last Update Date: 10/02/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9755 W. STATE HIGHWAY 22
RATCLIFF AR
72951-9000
US

IV. Provider business mailing address

PO BOX 130
RATCLIFF AR
72951-0130
US

V. Phone/Fax

Practice location:
  • Phone: 479-635-5300
  • Fax: 479-635-2010
Mailing address:
  • Phone: 479-635-5300
  • Fax: 479-635-4700

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberA01027
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: