Provider Demographics
NPI:1285865576
Name:DAUGHERTY, DECEMBER L (FNP-C)
Entity type:Individual
Prefix:
First Name:DECEMBER
Middle Name:L
Last Name:DAUGHERTY
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:704-384-6478
Mailing Address - Fax:
Practice Address - Street 1:200 HAWTHORNE LN
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28204-2515
Practice Address - Country:US
Practice Address - Phone:704-384-6478
Practice Address - Fax:704-384-8222
Is Sole Proprietor?:No
Enumeration Date:2009-08-04
Last Update Date:2019-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5004447363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5004447OtherNURSE PRACTITIONER
SCQNP081Medicaid
NC1285865576Medicaid
NC5004447OtherNURSE PRACTITIONER
NC1285865576Medicaid
NCNCP533EMedicare PIN
NCNCP533DMedicare PIN
NCNCP533CMedicare PIN