Provider Demographics
NPI:1376233189
Name:DOUGHERTY, SHANNON MARIE (NP)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:MARIE
Last Name:DOUGHERTY
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 1:31 TAMARACK ST APT 106C
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14220-1780
Mailing Address - Country:US
Mailing Address - Phone:716-860-4834
Mailing Address - Fax:
Practice Address - Street 1:31 TAMARACK ST APT 106C
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14220-1780
Practice Address - Country:US
Practice Address - Phone:716-860-4834
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-15
Last Update Date:2023-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY351180363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily