Provider Demographics
NPI:1992319917
Name:DOUGHERTY, MARY JEANNE (FNP-C)
Entity type:Individual
Prefix:
First Name:MARY JEANNE
Middle Name:
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 1:5612 SPRUCE TREE AVE
Mailing Address - Street 2:
Mailing Address - City:BETHESDA
Mailing Address - State:MD
Mailing Address - Zip Code:20814-1626
Mailing Address - Country:US
Mailing Address - Phone:301-584-5880
Mailing Address - Fax:
Practice Address - Street 1:5612 SPRUCE TREE AVE
Practice Address - Street 2:
Practice Address - City:BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20814-1626
Practice Address - Country:US
Practice Address - Phone:301-564-5880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-08
Last Update Date:2020-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR229606363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily