Provider Demographics
NPI:1770004400
Name:DOUGHERTY, VIRGINIA PAIGE (MS, RD, LDN)
Entity type:Individual
Prefix:
First Name:VIRGINIA
Middle Name:PAIGE
Last Name:DOUGHERTY
Suffix:
Gender:F
Credentials:MS, RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:726 26TH AVE STE 2
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99701-7043
Mailing Address - Country:US
Mailing Address - Phone:907-456-9051
Mailing Address - Fax:907-456-2980
Practice Address - Street 1:726 26TH AVE STE 2
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-7043
Practice Address - Country:US
Practice Address - Phone:907-456-9051
Practice Address - Fax:907-456-2980
Is Sole Proprietor?:No
Enumeration Date:2017-07-03
Last Update Date:2020-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK145129133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered