Provider Demographics
NPI:1144037672
Name:SHORT, BLESSING MARIE
Entity type:Individual
Prefix:
First Name:BLESSING
Middle Name:MARIE
Last Name:SHORT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5710 W ROOSEVELT ST
Mailing Address - Street 2:
Mailing Address - City:MONEE
Mailing Address - State:IL
Mailing Address - Zip Code:60449-8014
Mailing Address - Country:US
Mailing Address - Phone:815-662-7478
Mailing Address - Fax:
Practice Address - Street 1:10258 SOUTHWEST HWY # A
Practice Address - Street 2:
Practice Address - City:CHICAGO RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60415-1361
Practice Address - Country:US
Practice Address - Phone:708-346-9533
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-17
Last Update Date:2024-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085.010959363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant