Provider Demographics
NPI:1417423443
Name:DOUGHERTY, EDITH ANN (MSN, RN)
Entity Type:Individual
Prefix:
First Name:EDITH
Middle Name:ANN
Last Name:DOUGHERTY
Suffix:
Gender:F
Credentials:MSN, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:702 N GRANITE AVE # 98252
Mailing Address - Street 2:
Mailing Address - City:GRANITE FALLS
Mailing Address - State:WA
Mailing Address - Zip Code:98252-8774
Mailing Address - Country:US
Mailing Address - Phone:360-691-7791
Mailing Address - Fax:360-238-4416
Practice Address - Street 1:702 N GRANITE AVE
Practice Address - Street 2:
Practice Address - City:GRANITE FALLS
Practice Address - State:WA
Practice Address - Zip Code:98252-8774
Practice Address - Country:US
Practice Address - Phone:360-691-7791
Practice Address - Fax:360-238-4416
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-17
Last Update Date:2018-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60840166163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA60840166OtherREGISTERED NURSE LICENSE