Provider Demographics
NPI:1891001681
Name:DOHERTY, RENEE M (CNP)
Entity Type:Individual
Prefix:
First Name:RENEE
Middle Name:M
Last Name:DOHERTY
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:801 ROSEHILL RD
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49202-1762
Mailing Address - Country:US
Mailing Address - Phone:989-633-1400
Mailing Address - Fax:517-212-2009
Practice Address - Street 1:4760 FASHION SQUARE BLVD STE L-1
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48604-2620
Practice Address - Country:US
Practice Address - Phone:989-282-4003
Practice Address - Fax:888-491-7220
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-31
Last Update Date:2023-03-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4704177783363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4704177783OtherMI STATE LICENSE