Provider Demographics
NPI:1689095085
Name:DAUGHERTY, NATASHA MAE
Entity Type:Individual
Prefix:
First Name:NATASHA
Middle Name:MAE
Last Name:DAUGHERTY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:NATASHA
Other - Middle Name:MAE
Other - Last Name:MESHKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:22222 E JARVIS PL
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80018-4554
Mailing Address - Country:US
Mailing Address - Phone:630-551-6906
Mailing Address - Fax:
Practice Address - Street 1:22222 E JARVIS PL
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80018-4554
Practice Address - Country:US
Practice Address - Phone:630-551-6906
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-02
Last Update Date:2014-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN 272324164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse