Provider Demographics
NPI:1720473143
Name:DOUGHERTY, JUDITH EMERSON
Entity Type:Individual
Prefix:MRS
First Name:JUDITH
Middle Name:EMERSON
Last Name:DOUGHERTY
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:JUDITH
Other - Middle Name:MARGARET
Other - Last Name:EMERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP-BC
Mailing Address - Street 1:21041 BLACK CANYON RD
Mailing Address - Street 2:
Mailing Address - City:RAMONA
Mailing Address - State:CA
Mailing Address - Zip Code:92065-5412
Mailing Address - Country:US
Mailing Address - Phone:760-803-4942
Mailing Address - Fax:
Practice Address - Street 1:43 NEW SCOTLAND AVENUE
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12208
Practice Address - Country:US
Practice Address - Phone:518-262-3125
Practice Address - Fax:518-262-4415
Is Sole Proprietor?:No
Enumeration Date:2015-04-02
Last Update Date:2020-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF339946-1363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily