Provider Demographics
NPI:1659359412
Name:DAUGHERTY, COLLEEN
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:
Last Name:DAUGHERTY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3509 COPPERAS CV
Mailing Address - Street 2:
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76310-1121
Mailing Address - Country:US
Mailing Address - Phone:940-692-5446
Mailing Address - Fax:
Practice Address - Street 1:149 HART ST
Practice Address - Street 2:82 MEDICAL GROUP/CREDENTIALS
Practice Address - City:SHEPPARD AFB
Practice Address - State:TX
Practice Address - Zip Code:76311-3477
Practice Address - Country:US
Practice Address - Phone:940-676-6960
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT3334171000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171000000XOther Service ProvidersMilitary Health Care Provider
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXVAD 000OtherMILITARY