Provider Demographics
NPI:1962724906
Name:DOUGHTY, GINA M
Entity type:Individual
Prefix:
First Name:GINA
Middle Name:M
Last Name:DOUGHTY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6010 E. MOLLOY ROAD
Mailing Address - Street 2:
Mailing Address - City:E. SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13057
Mailing Address - Country:US
Mailing Address - Phone:315-432-5636
Mailing Address - Fax:
Practice Address - Street 1:6101 E MOLLOY RD
Practice Address - Street 2:
Practice Address - City:EAST SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13057-1175
Practice Address - Country:US
Practice Address - Phone:315-432-5636
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-18
Last Update Date:2010-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY293269-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse