Provider Demographics
NPI:1558587360
Name:DAUGHERTY, CAROL LYNN (PA)
Entity Type:Individual
Prefix:MS
First Name:CAROL
Middle Name:LYNN
Last Name:DAUGHERTY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3004 WHITTIER BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90023-1637
Mailing Address - Country:US
Mailing Address - Phone:323-264-0535
Mailing Address - Fax:323-264-0061
Practice Address - Street 1:3004 WHITTIER BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90023-1637
Practice Address - Country:US
Practice Address - Phone:323-264-0535
Practice Address - Fax:323-264-0061
Is Sole Proprietor?:No
Enumeration Date:2007-04-18
Last Update Date:2021-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA16107363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA16107Medicaid