Provider Demographics
NPI:1114573250
Name:DOUGHTY, SAVANNAH CHANTAE (APRN)
Entity Type:Individual
Prefix:
First Name:SAVANNAH
Middle Name:CHANTAE
Last Name:DOUGHTY
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:SAVANNAH
Other - Middle Name:CHANTAE
Other - Last Name:GAMMON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1201 E WADE WATTS AVE
Mailing Address - Street 2:
Mailing Address - City:MCALESTER
Mailing Address - State:OK
Mailing Address - Zip Code:74501-5655
Mailing Address - Country:US
Mailing Address - Phone:918-794-6008
Mailing Address - Fax:
Practice Address - Street 1:1201 E WADE WATTS AVE
Practice Address - Street 2:
Practice Address - City:MCALESTER
Practice Address - State:OK
Practice Address - Zip Code:74501-5655
Practice Address - Country:US
Practice Address - Phone:918-794-6008
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-14
Last Update Date:2021-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK101472363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily