Provider Demographics
NPI:1770946535
Name:DAUGHERTY, MONICA JEAN
Entity type:Individual
Prefix:
First Name:MONICA
Middle Name:JEAN
Last Name:DAUGHERTY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1213 MARIA LANE
Mailing Address - Street 2:
Mailing Address - City:IUKA
Mailing Address - State:MS
Mailing Address - Zip Code:38852
Mailing Address - Country:US
Mailing Address - Phone:662-423-3332
Mailing Address - Fax:
Practice Address - Street 1:1213 MARIA LN
Practice Address - Street 2:
Practice Address - City:IUKA
Practice Address - State:MS
Practice Address - Zip Code:38852-1135
Practice Address - Country:US
Practice Address - Phone:662-423-3332
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-30
Last Update Date:2016-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator