Healthcare Provider Details

I. General information

NPI: 1932668761
Provider Name (Legal Business Name): KAITLYN SHORTY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/19/2019
Last Update Date: 03/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 BROADWAY BLVD NE APT 607A
ALBUQUERQUE NM
87102-6420
US

IV. Provider business mailing address

PO BOX 3727
SHIPROCK NM
87420-3727
US

V. Phone/Fax

Practice location:
  • Phone: 505-787-0775
  • Fax:
Mailing address:
  • Phone: 505-486-9402
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: