Provider Demographics
NPI:1285626556
Name:DAUGHERTY, TAMMY M (MSN, CNM)
Entity Type:Individual
Prefix:MS
First Name:TAMMY
Middle Name:M
Last Name:DAUGHERTY
Suffix:
Gender:F
Credentials:MSN, CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:819 SOUTHWESTERN RUN
Mailing Address - Street 2:UNIT 1
Mailing Address - City:POLAND
Mailing Address - State:OH
Mailing Address - Zip Code:44514-3688
Mailing Address - Country:US
Mailing Address - Phone:330-629-9991
Mailing Address - Fax:330-629-9992
Practice Address - Street 1:819 SOUTHWESTERN RUN
Practice Address - Street 2:UNIT 1
Practice Address - City:POLAND
Practice Address - State:OH
Practice Address - Zip Code:44514-3688
Practice Address - Country:US
Practice Address - Phone:330-629-9991
Practice Address - Fax:330-629-9992
Is Sole Proprietor?:No
Enumeration Date:2005-08-22
Last Update Date:2011-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHNM-00180367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2016713Medicaid
OH2016713Medicaid
OHNM00621Medicare PIN