Provider Demographics
NPI:1598934978
Name:DOUGHERTY, LORRAINE (FNP)
Entity Type:Individual
Prefix:
First Name:LORRAINE
Middle Name:
Last Name:DOUGHERTY
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3400 E MARKET ST
Mailing Address - Street 2:
Mailing Address - City:LOGANSPORT
Mailing Address - State:IN
Mailing Address - Zip Code:46947-2295
Mailing Address - Country:US
Mailing Address - Phone:574-722-9633
Mailing Address - Fax:574-722-5987
Practice Address - Street 1:3400 E MARKET ST
Practice Address - Street 2:
Practice Address - City:LOGANSPORT
Practice Address - State:IN
Practice Address - Zip Code:46947-2295
Practice Address - Country:US
Practice Address - Phone:574-722-9633
Practice Address - Fax:574-722-5987
Is Sole Proprietor?:No
Enumeration Date:2008-02-29
Last Update Date:2012-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71002596A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200931110Medicaid
IN940670B2Medicare PIN
IN200931110Medicaid