Provider Demographics
NPI:1356780910
Name:DOUGHERTY, TIFFANY MARIE (FNP-BC)
Entity type:Individual
Prefix:MRS
First Name:TIFFANY
Middle Name:MARIE
Last Name:DOUGHERTY
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 MEDICAL PARK
Mailing Address - Street 2:
Mailing Address - City:WHEELING
Mailing Address - State:WV
Mailing Address - Zip Code:26003
Mailing Address - Country:US
Mailing Address - Phone:304-243-3308
Mailing Address - Fax:304-243-3328
Practice Address - Street 1:1 MEDICAL PARK
Practice Address - Street 2:
Practice Address - City:WHEELING
Practice Address - State:WV
Practice Address - Zip Code:26003
Practice Address - Country:US
Practice Address - Phone:304-243-3308
Practice Address - Fax:304-243-3328
Is Sole Proprietor?:No
Enumeration Date:2013-06-17
Last Update Date:2020-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOA.16020-NP363LF0000X
WV64499390200000X
OHRN332952390200000X
WVAPRN64499363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0105340Medicaid