Provider Demographics
NPI:1265652937
Name:DOHERTY, COLLEEN (NP)
Entity type:Individual
Prefix:
First Name:COLLEEN
Middle Name:
Last Name:DOHERTY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9920 CEDAR VIEW LN
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:IN
Mailing Address - Zip Code:47001-9466
Mailing Address - Country:US
Mailing Address - Phone:513-515-1751
Mailing Address - Fax:812-432-5579
Practice Address - Street 1:7800 JANDARACRES DR
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45248-2032
Practice Address - Country:US
Practice Address - Phone:513-515-1751
Practice Address - Fax:812-432-5579
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-26
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHNP-05704363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2501635Medicaid
OH2501635Medicaid
OHQ42859Medicare UPIN