Healthcare Provider Details

I. General information

NPI: 1962958298
Provider Name (Legal Business Name): COURTNEY SHORT FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2016
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1015 4TH AVE S
WISHEK ND
58495-0647
US

IV. Provider business mailing address

BOX 647
WISHEK ND
58495-0647
US

V. Phone/Fax

Practice location:
  • Phone: 701-452-2364
  • Fax: 701-452-4276
Mailing address:
  • Phone: 701-452-3207
  • Fax: 701-452-2179

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR36517
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: