Provider Demographics
NPI:1083784755
Name:DAUGHERTY, DEBORAH (NP)
Entity Type:Individual
Prefix:
First Name:DEBORAH
Middle Name:
Last Name:DAUGHERTY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3280 E STATE ROAD 32
Mailing Address - Street 2:
Mailing Address - City:WESTFIELD
Mailing Address - State:IN
Mailing Address - Zip Code:46074-8731
Mailing Address - Country:US
Mailing Address - Phone:612-225-1512
Mailing Address - Fax:
Practice Address - Street 1:3280 E STATE ROAD 32
Practice Address - Street 2:
Practice Address - City:WESTFIELD
Practice Address - State:IN
Practice Address - Zip Code:46074-8731
Practice Address - Country:US
Practice Address - Phone:612-225-1512
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-09
Last Update Date:2015-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71000364A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN232230OOMedicare PIN