Provider Demographics
NPI:1992207088
Name:DAUGHERTY, MIRA (APRN)
Entity Type:Individual
Prefix:
First Name:MIRA
Middle Name:
Last Name:DAUGHERTY
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:307 DALLAS DR
Mailing Address - Street 2:
Mailing Address - City:HUSTONVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40437-8304
Mailing Address - Country:US
Mailing Address - Phone:606-669-0537
Mailing Address - Fax:
Practice Address - Street 1:430 W MAIN ST
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:KY
Practice Address - Zip Code:40422-1888
Practice Address - Country:US
Practice Address - Phone:502-219-3488
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-05
Last Update Date:2021-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3012025363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100522600Medicaid