Provider Demographics
NPI:1811911647
Name:DAUGHERTY, PAULETTE (LMT, NCMMT)
Entity type:Individual
Prefix:MS
First Name:PAULETTE
Middle Name:
Last Name:DAUGHERTY
Suffix:
Gender:F
Credentials:LMT, NCMMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4005 HAYES AVE
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82001-2312
Mailing Address - Country:US
Mailing Address - Phone:307-256-8348
Mailing Address - Fax:307-432-0079
Practice Address - Street 1:1651 CAREY AVE STE 1B
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-4423
Practice Address - Country:US
Practice Address - Phone:307-256-8348
Practice Address - Fax:307-432-0079
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY06 00014838225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist