Provider Demographics
NPI:1578332516
Name:DAUGHERTY, GARY CHRISTOPOHER (LPN)
Entity Type:Individual
Prefix:MR
First Name:GARY
Middle Name:CHRISTOPOHER
Last Name:DAUGHERTY
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 WILEY CEMETERY LN
Mailing Address - Street 2:
Mailing Address - City:ROCKY TOP
Mailing Address - State:TN
Mailing Address - Zip Code:37769-5700
Mailing Address - Country:US
Mailing Address - Phone:865-659-7611
Mailing Address - Fax:
Practice Address - Street 1:107 WILEY CEMETERY LN
Practice Address - Street 2:
Practice Address - City:ROCKY TOP
Practice Address - State:TN
Practice Address - Zip Code:37769-5700
Practice Address - Country:US
Practice Address - Phone:865-659-7611
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-01
Last Update Date:2024-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN88802164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse