Healthcare Provider Details

I. General information

NPI: 1114687746
Provider Name (Legal Business Name): KERRY SHORT FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/22/2021
Last Update Date: 12/22/2021
Certification Date: 12/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1510 E FLOWER ST
PHOENIX AZ
85014-5698
US

IV. Provider business mailing address

1510 E FLOWER ST
PHOENIX AZ
85014-5698
US

V. Phone/Fax

Practice location:
  • Phone: 602-954-0444
  • Fax: 602-952-7146
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number268091
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: