Provider Demographics
NPI:1396019634
Name:DAUGHERTY, CHANNIN D (APRN)
Entity Type:Individual
Prefix:MS
First Name:CHANNIN
Middle Name:D
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 1:300 PASTEUR DR
Mailing Address - Street 2:
Mailing Address - City:STANFORD
Mailing Address - State:CA
Mailing Address - Zip Code:94305-2200
Mailing Address - Country:US
Mailing Address - Phone:650-723-4000
Mailing Address - Fax:650-498-5840
Practice Address - Street 1:21 CORPORATE WOODS
Practice Address - Street 2:10870 BENSON DRIVE #2160
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66210-6621
Practice Address - Country:US
Practice Address - Phone:833-357-3227
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-05
Last Update Date:2021-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3007357363LF0000X
CA23205363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily