Provider Demographics
NPI:1366035818
Name:DOHERTY, TANYA L
Entity Type:Individual
Prefix:
First Name:TANYA
Middle Name:L
Last Name:DOHERTY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 KELLY RD
Mailing Address - Street 2:
Mailing Address - City:BIG BEND
Mailing Address - State:WV
Mailing Address - Zip Code:26136-8100
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:420 KELLY RD
Practice Address - Street 2:
Practice Address - City:BIG BEND
Practice Address - State:WV
Practice Address - Zip Code:26136-8100
Practice Address - Country:US
Practice Address - Phone:304-354-6209
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-16
Last Update Date:2021-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker