Provider Demographics
NPI:1083387369
Name:DOUGHERTY SOPER, KATELYNN GENEVIEVE (DNP, FNP-BC)
Entity Type:Individual
Prefix:
First Name:KATELYNN
Middle Name:GENEVIEVE
Last Name:DOUGHERTY SOPER
Suffix:
Gender:F
Credentials:DNP, FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13 PATCHWORK CT
Mailing Address - Street 2:
Mailing Address - City:MONKTON
Mailing Address - State:MD
Mailing Address - Zip Code:21111-1604
Mailing Address - Country:US
Mailing Address - Phone:443-829-9609
Mailing Address - Fax:
Practice Address - Street 1:227 SAINT PAUL ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21202-2001
Practice Address - Country:US
Practice Address - Phone:410-783-5858
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-01
Last Update Date:2021-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR192850363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily