Provider Demographics
NPI:1295838399
Name:DAUGHERTY, MELANIE (APRN)
Entity Type:Individual
Prefix:
First Name:MELANIE
Middle Name:
Last Name:DAUGHERTY
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:399 FARMINGTON AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:FARMINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06032-1936
Mailing Address - Country:US
Mailing Address - Phone:860-246-2071
Mailing Address - Fax:860-674-4260
Practice Address - Street 1:399 FARMINGTON AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:FARMINGTON
Practice Address - State:CT
Practice Address - Zip Code:06032-1936
Practice Address - Country:US
Practice Address - Phone:860-246-2071
Practice Address - Fax:860-674-4260
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2015-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000268367A00000X
CT003029363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1295838399OtherANTHEM BLUE CROSS BLUE SHIELD
CT004243177Medicaid
NPP000Medicare UPIN