Provider Demographics
NPI:1710595558
Name:DAUGHERTY, SHANNON
Entity Type:Individual
Prefix:
First Name:SHANNON
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 1:3508 NORTHWESTERN DR
Mailing Address - Street 2:
Mailing Address - City:PARKERSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:26104-8062
Mailing Address - Country:US
Mailing Address - Phone:304-488-2816
Mailing Address - Fax:
Practice Address - Street 1:2601 UNITY PL
Practice Address - Street 2:
Practice Address - City:PARKERSBURG
Practice Address - State:WV
Practice Address - Zip Code:26101-7169
Practice Address - Country:US
Practice Address - Phone:304-488-2618
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-17
Last Update Date:2020-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant