Provider Demographics
NPI:1093918310
Name:DOHERTY, PAMELA JILL (RDLD)
Entity Type:Individual
Prefix:MRS
First Name:PAMELA
Middle Name:JILL
Last Name:DOHERTY
Suffix:
Gender:F
Credentials:RDLD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6181 STATE ROUTE 734
Mailing Address - Street 2:
Mailing Address - City:JAMESTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:45335-8706
Mailing Address - Country:US
Mailing Address - Phone:937-238-6096
Mailing Address - Fax:
Practice Address - Street 1:2690 C ST, BLDG 571 (AREA B) WRIGHT-FIELD FITNESS CTR
Practice Address - Street 2:(AREA B) WRIGHT-FIELD FITNESS
Practice Address - City:WRIGHT-PATTERSON AFB
Practice Address - State:OH
Practice Address - Zip Code:45433-5350
Practice Address - Country:US
Practice Address - Phone:937-904-9361
Practice Address - Fax:937-904-9396
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLD. 5368133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered