Provider Demographics
NPI:1851991194
Name:DOHERTY, KATELYN ALYSSA (NP)
Entity Type:Individual
Prefix:
First Name:KATELYN
Middle Name:ALYSSA
Last Name:DOHERTY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:5 EVA LN
Mailing Address - Street 2:
Mailing Address - City:FARMINGVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11738-1010
Mailing Address - Country:US
Mailing Address - Phone:631-624-7943
Mailing Address - Fax:
Practice Address - Street 1:45 RESEARCH WAY STE 108
Practice Address - Street 2:
Practice Address - City:EAST SETAUKET
Practice Address - State:NY
Practice Address - Zip Code:11733-6401
Practice Address - Country:US
Practice Address - Phone:631-941-2000
Practice Address - Fax:631-941-2010
Is Sole Proprietor?:No
Enumeration Date:2020-10-27
Last Update Date:2021-11-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NYF309820-01363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner