Provider Demographics
NPI:1225740913
Name:DOUGHERTY, PAMELA MARIE (LPN)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:MARIE
Last Name:DOUGHERTY
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1915 BRIARWOOD ST
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44641-9103
Mailing Address - Country:US
Mailing Address - Phone:330-904-1286
Mailing Address - Fax:
Practice Address - Street 1:1915 BRIARWOOD ST
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:OH
Practice Address - Zip Code:44641-9103
Practice Address - Country:US
Practice Address - Phone:330-904-1286
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-14
Last Update Date:2022-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLPN.054326.MEDS-IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse