Provider Demographics
NPI:1679136477
Name:DOUGHERTY, KELLIE JO
Entity Type:Individual
Prefix:
First Name:KELLIE
Middle Name:JO
Last Name:DOUGHERTY
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 1:146 N WESTERN AVE UNIT G
Mailing Address - Street 2:
Mailing Address - City:NEENAH
Mailing Address - State:WI
Mailing Address - Zip Code:54956-2297
Mailing Address - Country:US
Mailing Address - Phone:920-410-9605
Mailing Address - Fax:
Practice Address - Street 1:146 N WESTERN AVE UNIT G
Practice Address - Street 2:
Practice Address - City:NEENAH
Practice Address - State:WI
Practice Address - Zip Code:54956-2297
Practice Address - Country:US
Practice Address - Phone:920-410-9605
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-17
Last Update Date:2019-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95133947163W00000X
WI174687163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse