Provider Demographics
NPI:1083621270
Name:DAUGHERTY, ALICE MARIE (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:MS
First Name:ALICE
Middle Name:MARIE
Last Name:DAUGHERTY
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Gender:F
Credentials:NURSE PRACTITIONER
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Mailing Address - Street 1:26522 LA ALAMEDA
Mailing Address - Street 2:SUITE 120
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92691-6330
Mailing Address - Country:US
Mailing Address - Phone:949-282-1671
Mailing Address - Fax:949-367-0518
Practice Address - Street 1:27871 MEDICAL CENTER RD
Practice Address - Street 2:SUITE 240
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92691-6404
Practice Address - Country:US
Practice Address - Phone:949-364-5090
Practice Address - Fax:949-542-8710
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2013-01-23
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Provider Licenses
StateLicense IDTaxonomies
CA498631363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABI056ZMedicare PIN