1407364342 NPI number — CAROLINE DAUGHERTY

Table of content: CAROLINE DAUGHERTY (NPI 1407364342)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407364342 NPI number — CAROLINE DAUGHERTY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DAUGHERTY
Provider First Name:
CAROLINE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
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:
1407364342
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/10/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3101 MAGIC HOLLOW BLVD, VIRGINIA BEACH, VA 23453
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VIRGINIA BEACH
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23453-1177
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
757-639-2218
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2076 S INDEPENDENCE BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VIRGINIA BEACH
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23453-4779
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
757-622-7272
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/12/2018

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: 106S00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103K00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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