Provider Demographics
NPI:1962699637
Name:DOUGHERTY, DENISE M (FNP-C)
Entity type:Individual
Prefix:MS
First Name:DENISE
Middle Name:M
Last Name:DOUGHERTY
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 1:1231 S 3RD ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19147-5303
Mailing Address - Country:US
Mailing Address - Phone:267-886-9507
Mailing Address - Fax:
Practice Address - Street 1:6501 HARBISON AVE
Practice Address - Street 2:
Practice Address - City:PHILA
Practice Address - State:PA
Practice Address - Zip Code:19149-2912
Practice Address - Country:US
Practice Address - Phone:215-333-4300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-26
Last Update Date:2009-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP009356363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA122859XRUMedicare PIN
PA122859XRNMedicare PIN