Provider Demographics
NPI:1437555885
Name:DOHERTY, KEVIN L (RN)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:L
Last Name:DOHERTY
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:597 CENTER AVE
Mailing Address - Street 2:SUITE 200A
Mailing Address - City:MARTINEZ
Mailing Address - State:CA
Mailing Address - Zip Code:94553-4640
Mailing Address - Country:US
Mailing Address - Phone:925-676-6735
Mailing Address - Fax:925-676-6465
Practice Address - Street 1:597 CENTER AVE
Practice Address - Street 2:SUITE 200A
Practice Address - City:MARTINEZ
Practice Address - State:CA
Practice Address - Zip Code:94553-4640
Practice Address - Country:US
Practice Address - Phone:925-676-6735
Practice Address - Fax:925-676-6465
Is Sole Proprietor?:No
Enumeration Date:2014-11-12
Last Update Date:2014-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA468098163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0400XNursing Service ProvidersRegistered NurseCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA468098OtherREGISTERED NUSE LICENSE