Provider Demographics
NPI:1609544147
Name:DOUGHERTY, GIANISA NICOLE (ATC)
Entity Type:Individual
Prefix:
First Name:GIANISA
Middle Name:NICOLE
Last Name:DOUGHERTY
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10012 THORNTON WAY APT SUITE
Mailing Address - Street 2:
Mailing Address - City:HUNTLEY
Mailing Address - State:IL
Mailing Address - Zip Code:60142-2390
Mailing Address - Country:US
Mailing Address - Phone:224-523-0191
Mailing Address - Fax:
Practice Address - Street 1:650 LEM MORRISON DRIVE
Practice Address - Street 2:
Practice Address - City:AUBRUN
Practice Address - State:AL
Practice Address - Zip Code:36830
Practice Address - Country:US
Practice Address - Phone:224-523-0191
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-31
Last Update Date:2021-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer