Provider Demographics
NPI:1962710434
Name:DAUGHERTY, DANIEL LEE JR (STNA)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:LEE
Last Name:DAUGHERTY
Suffix:JR
Gender:M
Credentials:STNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4567 SPRING HILL RD
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:OH
Mailing Address - Zip Code:43056-9022
Mailing Address - Country:US
Mailing Address - Phone:740-763-2024
Mailing Address - Fax:740-281-0028
Practice Address - Street 1:4567 SPRING HILL RD
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:OH
Practice Address - Zip Code:43056-9022
Practice Address - Country:US
Practice Address - Phone:740-763-2024
Practice Address - Fax:740-281-0028
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-18
Last Update Date:2010-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH401115450710376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide