Provider Demographics
NPI:1831561372
Name:DAUGHERTY, MOLLY PATRICIA (RN)
Entity type:Individual
Prefix:
First Name:MOLLY
Middle Name:PATRICIA
Last Name:DAUGHERTY
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:832 ROLLINGWOOD LN
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1053
Mailing Address - Country:US
Mailing Address - Phone:260-385-0966
Mailing Address - Fax:
Practice Address - Street 1:832 ROLLINGWOOD LN
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-1053
Practice Address - Country:US
Practice Address - Phone:260-385-0966
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-23
Last Update Date:2015-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28084371A163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse