Provider Demographics
NPI:1790174514
Name:DOUGHERTY, OLIVIA LEAH (LPN)
Entity Type:Individual
Prefix:MISS
First Name:OLIVIA
Middle Name:LEAH
Last Name:DOUGHERTY
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:MISS
Other - First Name:OLIVIA
Other - Middle Name:LEAH
Other - Last Name:DOUGHERTY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPN
Mailing Address - Street 1:662 BEACH RD
Mailing Address - Street 2:
Mailing Address - City:ANGOLA
Mailing Address - State:NY
Mailing Address - Zip Code:14006-9784
Mailing Address - Country:US
Mailing Address - Phone:716-771-9291
Mailing Address - Fax:
Practice Address - Street 1:662 BEACH RD
Practice Address - Street 2:
Practice Address - City:ANGOLA
Practice Address - State:NY
Practice Address - Zip Code:14006-9784
Practice Address - Country:US
Practice Address - Phone:716-771-9291
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-16
Last Update Date:2015-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY314664-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse