Provider Demographics
NPI:1669441044
Name:DAUGHERTY, SHANNON (NP)
Entity Type:Individual
Prefix:MS
First Name:SHANNON
Middle Name:
Last Name:DAUGHERTY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 GUTHRIE SQ
Mailing Address - Street 2:
Mailing Address - City:SAYRE
Mailing Address - State:PA
Mailing Address - Zip Code:18840-1625
Mailing Address - Country:US
Mailing Address - Phone:570-888-5858
Mailing Address - Fax:
Practice Address - Street 1:31 ARNOT RD
Practice Address - Street 2:SUITE A
Practice Address - City:HORSEHEADS
Practice Address - State:NY
Practice Address - Zip Code:14845-8533
Practice Address - Country:US
Practice Address - Phone:607-739-3874
Practice Address - Fax:607-739-3632
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2011-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF320015-1363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYCC8362OtherRR MEDICARE GROUP
NYP00098788OtherRR MEDICARE PIN
NY02388796Medicaid
NYRA1736Medicare ID - Type Unspecified
NY02388796Medicaid