Provider Demographics
NPI:1588854830
Name:DOHERTY, JOAN MARIE (RN)
Entity Type:Individual
Prefix:MS
First Name:JOAN
Middle Name:MARIE
Last Name:DOHERTY
Suffix:
Gender:F
Credentials:RN
Other - Prefix:MS
Other - First Name:JOAN
Other - Middle Name:TOBIN
Other - Last Name:DOGHERTY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RN
Mailing Address - Street 1:PO BOX 251
Mailing Address - Street 2:
Mailing Address - City:NEW SUFFOLK
Mailing Address - State:NY
Mailing Address - Zip Code:11956-0251
Mailing Address - Country:US
Mailing Address - Phone:631-734-6167
Mailing Address - Fax:
Practice Address - Street 1:1095 CUSTER AVE
Practice Address - Street 2:
Practice Address - City:SOUTHOLD
Practice Address - State:NY
Practice Address - Zip Code:11971-3376
Practice Address - Country:US
Practice Address - Phone:631-765-0031
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-01
Last Update Date:2007-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2057611163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02592652Medicaid