Provider Demographics
NPI:1871670372
Name:DOUGHERTY, DEBORAH (NP)
Entity Type:Individual
Prefix:
First Name:DEBORAH
Middle Name:
Last Name:DOUGHERTY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:520 TRACY RD
Mailing Address - Street 2:
Mailing Address - City:NEW WHITELAND
Mailing Address - State:IN
Mailing Address - Zip Code:46184-9373
Mailing Address - Country:US
Mailing Address - Phone:317-535-7447
Mailing Address - Fax:
Practice Address - Street 1:520 TRACY RD
Practice Address - Street 2:
Practice Address - City:NEW WHITELAND
Practice Address - State:IN
Practice Address - Zip Code:46184-9373
Practice Address - Country:US
Practice Address - Phone:317-535-7447
Practice Address - Fax:317-535-0262
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2010-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71000704363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200452810Medicaid
IN151850AAMedicare PIN
INP18810Medicare UPIN
970018590Medicare PIN
IN151720GMedicare PIN
IN200452810Medicaid