Provider Demographics
NPI:1861919441
Name:SHORT, EDITH
Entity type:Individual
Prefix:
First Name:EDITH
Middle Name:
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 1:484 STONY KILL RD
Mailing Address - Street 2:
Mailing Address - City:ACCORD
Mailing Address - State:NY
Mailing Address - Zip Code:12404-5432
Mailing Address - Country:US
Mailing Address - Phone:845-389-9449
Mailing Address - Fax:845-331-8427
Practice Address - Street 1:484 STONY KILL RD
Practice Address - Street 2:
Practice Address - City:ACCORD
Practice Address - State:NY
Practice Address - Zip Code:12404-5432
Practice Address - Country:US
Practice Address - Phone:845-389-9449
Practice Address - Fax:845-331-8427
Is Sole Proprietor?:No
Enumeration Date:2017-08-24
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY637444163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY$$$$$$$$$Medicaid