Provider Demographics
NPI:1518162205
Name:DOUGHERTY, NINA
Entity Type:Individual
Prefix:MS
First Name:NINA
Middle Name:
Last Name:DOUGHERTY
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:NINA
Other - Middle Name:
Other - Last Name:DOUGHERTY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MS,RD
Mailing Address - Street 1:28 GENERAL SAGE DR
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-6395
Mailing Address - Country:US
Mailing Address - Phone:505-988-1899
Mailing Address - Fax:505-988-1899
Practice Address - Street 1:28 GENERAL SAGE DR
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-6395
Practice Address - Country:US
Practice Address - Phone:505-988-1899
Practice Address - Fax:505-988-1899
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM054133VN1004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1004XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Pediatric
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM001179553000OtherCRS-1FILER'S KIT