Provider Demographics
NPI:1154358752
Name:DOUGHERTY, SHAYNE KING (CRNP)
Entity type:Individual
Prefix:MRS
First Name:SHAYNE
Middle Name:KING
Last Name:DOUGHERTY
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3400 CIVIC CENTER BLVD.
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104-4399
Mailing Address - Country:US
Mailing Address - Phone:267-426-5112
Mailing Address - Fax:215-590-3053
Practice Address - Street 1:32 GREENVIEW LN
Practice Address - Street 2:
Practice Address - City:HAVERTOWN
Practice Address - State:PA
Practice Address - Zip Code:19083-4313
Practice Address - Country:US
Practice Address - Phone:610-924-9763
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP007565363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics