1912268038 NPI number — ALISSA K DAUGHERTY MD

Table of content: ALISSA K DAUGHERTY MD (NPI 1912268038)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912268038 NPI number — ALISSA K DAUGHERTY MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DAUGHERTY
Provider First Name:
ALISSA
Provider Middle Name:
K
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1912268038
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/19/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4044 FORT CAMPBELL BLVD
Provider Second Line Business Mailing Address:
PMB# 124
Provider Business Mailing Address City Name:
HOPKINSVILLE
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
42240-4950
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
502-322-5219
Provider Business Mailing Address Fax Number:
999-999-9999

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4044 FORT CAMPBELL BLVD
Provider Second Line Business Practice Location Address:
PMB# 124
Provider Business Practice Location Address City Name:
HOPKINSVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42240-4950
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-839-2298
Provider Business Practice Location Address Fax Number:
999-999-9999
Provider Enumeration Date:
06/05/2012

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  47177 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 7100253410 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




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