Provider Demographics
NPI:1922033174
Name:DAUGHERTY, MICHELLE LYN (STNA/HHA)
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:LYN
Last Name:DAUGHERTY
Suffix:
Gender:F
Credentials:STNA/HHA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:142 E WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:WADSWORTH
Mailing Address - State:OH
Mailing Address - Zip Code:44281-1366
Mailing Address - Country:US
Mailing Address - Phone:330-687-5742
Mailing Address - Fax:
Practice Address - Street 1:142 E WALNUT ST
Practice Address - Street 2:
Practice Address - City:WADSWORTH
Practice Address - State:OH
Practice Address - Zip Code:44281-1366
Practice Address - Country:US
Practice Address - Phone:330-687-5742
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH400321170104376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2495134Medicaid