Provider Demographics
NPI:1730104837
Name:DOUGHERTY, DEBRA S (ARNP)
Entity Type:Individual
Prefix:
First Name:DEBRA
Middle Name:S
Last Name:DOUGHERTY
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2234 COLONIAL BLVD
Mailing Address - Street 2:ATTN: PAYER CONTRACTING & RELATIONS DEPT.
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-1412
Mailing Address - Country:US
Mailing Address - Phone:239-931-7342
Mailing Address - Fax:239-931-7385
Practice Address - Street 1:200 3RD AVE W
Practice Address - Street 2:SUITE 210
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34205-8626
Practice Address - Country:US
Practice Address - Phone:941-792-0340
Practice Address - Fax:941-794-2251
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2015-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71001790363L00000X
KY2258P363LW0102X
FL9338893363LW0102X
FLARNP9338893363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY2447974000OtherPASSPORT ADVANTAGE
7663234OtherAETNA
KY78001427Medicaid
FLP01420776OtherRR MEDICARE
IN070134OtherSIHO
IN000000381896OtherANTHEM BCBS
IN200404560Medicaid
KY50006753OtherPASSPORT KY MEDICAID
FLY0C29OtherBCBS
IN000000381896OtherANTHEM BCBS
7663234OtherAETNA
FLY0C29OtherBCBS
KY50006753OtherPASSPORT KY MEDICAID
IN412840SSMedicare PIN