Provider Demographics
NPI:1558384487
Name:DOUGHERTY, ANNE (CRNP)
Entity Type:Individual
Prefix:
First Name:ANNE
Middle Name:
Last Name:DOUGHERTY
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1256 WATERFORD DR STE 230
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60504-4511
Mailing Address - Country:US
Mailing Address - Phone:630-978-6204
Mailing Address - Fax:
Practice Address - Street 1:472 ROUTE 47
Practice Address - Street 2:
Practice Address - City:SUGAR GROVE
Practice Address - State:IL
Practice Address - Zip Code:60554-8107
Practice Address - Country:US
Practice Address - Phone:630-466-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2023-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209023170363L00000X, 363LF0000X
NY333962363LF0000X
MDR171561363L00000X
PASP006072B363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA2512931OtherHIGHMARK BLUE SHIELD-WMG
PA1589494OtherGATEWAY MEDICARE ASSURED-WMG
PA1589494OtherGATEWAY MEDICARE ASSURED-WMG
PAP00860324Medicare PIN