Provider Demographics
NPI:1093339541
Name:DOCHERTY, ROBERT E (RN)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:E
Last Name:DOCHERTY
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:402 W LAKE ST
Mailing Address - Street 2:
Mailing Address - City:FRIENDSHIP
Mailing Address - State:WI
Mailing Address - Zip Code:53934-9699
Mailing Address - Country:US
Mailing Address - Phone:608-339-3331
Mailing Address - Fax:
Practice Address - Street 1:402 W LAKE ST
Practice Address - Street 2:
Practice Address - City:FRIENDSHIP
Practice Address - State:WI
Practice Address - Zip Code:53934-9699
Practice Address - Country:US
Practice Address - Phone:608-339-3331
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-01
Last Update Date:2021-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI226369163W00000X
WI10357363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse