Provider Demographics
NPI:1548596711
Name:DAUGHERTY, KRISTIN MICHELLE (MD)
Entity Type:Individual
Prefix:DR
First Name:KRISTIN
Middle Name:MICHELLE
Last Name:DAUGHERTY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 W CHESTNUT ST
Mailing Address - Street 2:3402
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60610-3175
Mailing Address - Country:US
Mailing Address - Phone:304-893-8940
Mailing Address - Fax:
Practice Address - Street 1:1423 CHICAGO RD
Practice Address - Street 2:
Practice Address - City:CHICAGO HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60411-3400
Practice Address - Country:US
Practice Address - Phone:708-709-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-23
Last Update Date:2013-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH57.016186146D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes146D00000XEmergency Medical Service ProvidersPersonal Emergency Response Attendant