Provider Demographics
NPI:1245854819
Name:DAUGHERTY, LAURA KATHLEEN (NP)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:KATHLEEN
Last Name:DAUGHERTY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:
Other - Last Name:BURNS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:6626 E 75TH ST STE 500
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-2890
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8075 N SHADELAND AVE STE 310
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46250-2694
Practice Address - Country:US
Practice Address - Phone:317-621-8000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-29
Last Update Date:2022-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28201025A163W00000X, 363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
INQ00237650OtherRAILROAD MEDICARE
IN300040788Medicaid