Provider Demographics
NPI:1336407808
Name:DAUGHERTY, TARSHENE NICOLE (LMP)
Entity Type:Individual
Prefix:
First Name:TARSHENE
Middle Name:NICOLE
Last Name:DAUGHERTY
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16703 SE MCGILLIVRAY BLVD
Mailing Address - Street 2:#215
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98683-4300
Mailing Address - Country:US
Mailing Address - Phone:360-883-2450
Mailing Address - Fax:866-935-1910
Practice Address - Street 1:16703 SE MCGILLIVRAY BLVD
Practice Address - Street 2:#215
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98683-4300
Practice Address - Country:US
Practice Address - Phone:360-883-2450
Practice Address - Fax:866-935-1910
Is Sole Proprietor?:No
Enumeration Date:2012-05-02
Last Update Date:2012-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00020385174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist