1871231829 NPI number — CORA H CREASEY SHORT

Table of content: CORA H CREASEY SHORT (NPI 1871231829)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871231829 NPI number — CORA H CREASEY SHORT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CREASEY SHORT
Provider First Name:
CORA
Provider Middle Name:
H
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1871231829
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/20/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
153 WASHINGTON STREET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
AMHERST
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
24521
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
434-946-9386
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
287 LEARNING LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MADISON HEIGHTS
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
24572-2326
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
434-846-2151
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/20/2022

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 224Z00000X , with the licence number:  0131002597 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)