Provider Demographics
NPI:1124669221
Name:DOUGHERTY, JAIME LOUISE (MSN, APRN, FNP-BC)
Entity type:Individual
Prefix:MRS
First Name:JAIME
Middle Name:LOUISE
Last Name:DOUGHERTY
Suffix:
Gender:F
Credentials:MSN, APRN, FNP-BC
Other - Prefix:MRS
Other - First Name:JAIME
Other - Middle Name:LOUISE
Other - Last Name:DOUGHERTY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:JAIME DOUGHERTY, FNP
Mailing Address - Street 1:1604 WILLOW VIS
Mailing Address - Street 2:
Mailing Address - City:ROUND ROCK
Mailing Address - State:TX
Mailing Address - Zip Code:78664-7937
Mailing Address - Country:US
Mailing Address - Phone:512-694-0124
Mailing Address - Fax:
Practice Address - Street 1:1604 WILLOW VIS
Practice Address - Street 2:
Practice Address - City:ROUND ROCK
Practice Address - State:TX
Practice Address - Zip Code:78664-7937
Practice Address - Country:US
Practice Address - Phone:512-694-0124
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-01
Last Update Date:2020-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP143780363LF0000X
NDR48645363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
1461364730OtherNATIONAL REGISTRY OF CERTIFIED MEDICAL EXAMINERS