Healthcare Provider Details

I. General information

NPI: 1316885106
Provider Name (Legal Business Name): MARY SHORT RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2026
Last Update Date: 03/23/2026
Certification Date: 03/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2412 E WASHINGTON ST STE 4A
BLOOMINGTON IL
61704-1613
US

IV. Provider business mailing address

2412 E WASHINGTON ST STE 4A
BLOOMINGTON IL
61704-1613
US

V. Phone/Fax

Practice location:
  • Phone: 309-585-2116
  • Fax: 309-585-2152
Mailing address:
  • Phone: 309-585-2116
  • Fax: 309-585-2152

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041415946
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: