Basic Information
| Provider Information | |||||||||
| NPI: | 1558609099 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHORT | ||||||||
| FirstName: | KATE | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 677 | ||||||||
| Address2: | |||||||||
| City: | SCOTTSBURG | ||||||||
| State: | IN | ||||||||
| PostalCode: | 471700677 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 2502 25TH ST | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 472013728 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8123728883 | ||||||||
| FaxNumber: | 8123728964 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/17/2013 | ||||||||
| LastUpdateDate: | 01/30/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/30/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 71004236A | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 201150620 | 05 | IN | MEDICAID | 000000991689 | 01 | IN | ANTHEM PIN | OTHER |