Provider Demographics
NPI:1770534620
Name:DOUGHERTY, DIANE L (ARNP)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:L
Last Name:DOUGHERTY
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:501 E BROADWAY
Mailing Address - Street 2:SUITE 290
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202-1785
Mailing Address - Country:US
Mailing Address - Phone:502-217-8221
Mailing Address - Fax:502-217-5056
Practice Address - Street 1:215 CENTRAL AVE STE 110
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40208-1449
Practice Address - Country:US
Practice Address - Phone:502-852-6479
Practice Address - Fax:502-852-6449
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2011-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3002140363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily