Provider Demographics
NPI:1609108265
Name:DOHERTY, DIANE ELAINE
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:ELAINE
Last Name:DOHERTY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:DIANE
Other - Middle Name:ELAINE
Other - Last Name:EMLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LVN
Mailing Address - Street 1:9098 W. RIDGE LINE
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-9103
Mailing Address - Country:US
Mailing Address - Phone:208-651-2186
Mailing Address - Fax:208-769-7960
Practice Address - Street 1:9098 W RIDGE LINE LN
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-9103
Practice Address - Country:US
Practice Address - Phone:208-651-2186
Practice Address - Fax:208-769-7960
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-08
Last Update Date:2010-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN 3801164X00000X
ID376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse
No376K00000XNursing Service Related ProvidersNurse's Aide