Provider Demographics
NPI:1205421872
Name:DAUGHERTY, EDONTRE MALIK
Entity type:Individual
Prefix:
First Name:EDONTRE
Middle Name:MALIK
Last Name:DAUGHERTY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5722 KETCHAM AVE
Mailing Address - Street 2:
Mailing Address - City:ASHTABULA
Mailing Address - State:OH
Mailing Address - Zip Code:44004-9779
Mailing Address - Country:US
Mailing Address - Phone:440-813-9675
Mailing Address - Fax:
Practice Address - Street 1:5722 KETCHAM AVE
Practice Address - Street 2:
Practice Address - City:ASHTABULA
Practice Address - State:OH
Practice Address - Zip Code:44004-9779
Practice Address - Country:US
Practice Address - Phone:440-813-9675
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-05
Last Update Date:2021-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide