Provider Demographics
NPI:1972129476
Name:DOUGHERTY, MICHAEL DEVIN (ARNP)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:DEVIN
Last Name:DOUGHERTY
Suffix:
Gender:M
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2348 ROYAL OAKS DR
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32309-2930
Mailing Address - Country:US
Mailing Address - Phone:850-545-8533
Mailing Address - Fax:
Practice Address - Street 1:UNIT 33100
Practice Address - Street 2:
Practice Address - City:APO
Practice Address - State:AE
Practice Address - Zip Code:09180
Practice Address - Country:DE
Practice Address - Phone:637-194-6457
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-19
Last Update Date:2023-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11007658363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily