Provider Demographics
NPI:1306815006
Name:DOHERTY, NANCY M (NP)
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:M
Last Name:DOHERTY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3200 GRANT ST
Mailing Address - Street 2:ATTN ACCOUNTING DEPARTMENT
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201
Mailing Address - Country:US
Mailing Address - Phone:847-492-4871
Mailing Address - Fax:847-570-3426
Practice Address - Street 1:1100 PEMBRIDGE DR
Practice Address - Street 2:
Practice Address - City:LAKE FOREST
Practice Address - State:IL
Practice Address - Zip Code:60045
Practice Address - Country:US
Practice Address - Phone:847-604-6700
Practice Address - Fax:847-570-3426
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
K16229Medicare ID - Type Unspecified
K13701Medicare ID - Type Unspecified
210708Medicare ID - Type UnspecifiedGROUP
211076Medicare ID - Type UnspecifiedGROUP