Provider Demographics
NPI:1063420420
Name:DOUGHERTY, AMY MARIE (PT)
Entity type:Individual
Prefix:MRS
First Name:AMY
Middle Name:MARIE
Last Name:DOUGHERTY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 PINNACLE CT
Mailing Address - Street 2:
Mailing Address - City:KITTY HAWK
Mailing Address - State:NC
Mailing Address - Zip Code:27949
Mailing Address - Country:US
Mailing Address - Phone:252-255-5348
Mailing Address - Fax:252-255-5348
Practice Address - Street 1:102 PINNACLE CT
Practice Address - Street 2:
Practice Address - City:KITTY HAWK
Practice Address - State:NC
Practice Address - Zip Code:27949
Practice Address - Country:US
Practice Address - Phone:252-255-5348
Practice Address - Fax:252-255-5348
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2010-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2399225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
2504083Medicare ID - Type Unspecified
NC2501620AMedicare PIN