Provider Demographics
NPI:1295708774
Name:DOUGHERTY, SUSAN E (NP-CNM)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:E
Last Name:DOUGHERTY
Suffix:
Gender:F
Credentials:NP-CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:535 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:OLEAN
Mailing Address - State:NY
Mailing Address - Zip Code:14760
Mailing Address - Country:US
Mailing Address - Phone:716-372-0141
Mailing Address - Fax:716-372-6421
Practice Address - Street 1:535 MAIN ST
Practice Address - Street 2:
Practice Address - City:OLEAN
Practice Address - State:NY
Practice Address - Zip Code:14760
Practice Address - Country:US
Practice Address - Phone:716-372-0141
Practice Address - Fax:716-372-6421
Is Sole Proprietor?:No
Enumeration Date:2006-02-07
Last Update Date:2016-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF420192363LW0102X
NYF000461367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01436364Medicaid
NYRA2335Medicare ID - Type Unspecified
NY01436364Medicaid