Provider Demographics
NPI:1225074578
Name:DOUGHERTY, LAURIE L (CRNP)
Entity Type:Individual
Prefix:
First Name:LAURIE
Middle Name:L
Last Name:DOUGHERTY
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:LAURIE
Other - Middle Name:L
Other - Last Name:DOUGHERTY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CRNP
Mailing Address - Street 1:3400 SPRUCE ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104-4206
Mailing Address - Country:US
Mailing Address - Phone:215-662-4000
Mailing Address - Fax:215-745-4749
Practice Address - Street 1:3400 SPRUCE ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-4206
Practice Address - Country:US
Practice Address - Phone:215-662-4000
Practice Address - Fax:215-463-3820
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2011-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP007792363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health