Healthcare Provider Details

I. General information

NPI: 1891451936
Provider Name (Legal Business Name): AMY NICOLE SHORTT ACNP-AG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/12/2021
Last Update Date: 08/05/2025
Certification Date: 08/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

271 MEDICAL PARK BLVD
BRISTOL TN
37620-7455
US

IV. Provider business mailing address

1021 W OAKLAND AVE STE 310
JOHNSON CITY TN
37604-2192
US

V. Phone/Fax

Practice location:
  • Phone: 423-274-8600
  • Fax:
Mailing address:
  • Phone: 423-952-2111
  • Fax: 423-282-1657

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number2021040583
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code363LC1500X
TaxonomyCommunity Health Nurse Practitioner
License Number0024190101
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number36565
License Number StateTN
# 4
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number0024190101
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: