Healthcare Provider Details

I. General information

NPI: 1871331561
Provider Name (Legal Business Name): TIFFANY JO SHORT BA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/17/2024
Last Update Date: 09/18/2026
Certification Date: 09/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

956 YATES AVE
GRAFTON WV
26354-1683
US

IV. Provider business mailing address

222 TALL TIMBER LN
CLARKSBURG WV
26301-5746
US

V. Phone/Fax

Practice location:
  • Phone: 304-290-8964
  • Fax:
Mailing address:
  • Phone: 304-997-3442
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: