Provider Demographics
NPI:1417220658
Name:DOUGHERTY, DELIA
Entity Type:Individual
Prefix:
First Name:DELIA
Middle Name:
Last Name:DOUGHERTY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:DELIA
Other - Middle Name:PATRICE
Other - Last Name:DOUGHERTY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:27 GAINSBOROUGH RD
Mailing Address - Street 2:
Mailing Address - City:HOLBROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11741-2808
Mailing Address - Country:US
Mailing Address - Phone:631-472-0213
Mailing Address - Fax:
Practice Address - Street 1:27 GAINSBOROUGH RD
Practice Address - Street 2:
Practice Address - City:HOLBROOK
Practice Address - State:NY
Practice Address - Zip Code:11741-2808
Practice Address - Country:US
Practice Address - Phone:631-472-0213
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-20
Last Update Date:2012-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY597548163WM0705X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical