1548513690 NPI number — MISS NDOME CHAVONE DOUGHERTY ANP-C

Table of content: MISS NDOME CHAVONE DOUGHERTY ANP-C (NPI 1548513690)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548513690 NPI number — MISS NDOME CHAVONE DOUGHERTY ANP-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DOUGHERTY
Provider First Name:
NDOME
Provider Middle Name:
CHAVONE
Provider Name Prefix Text:
MISS
Provider Name Suffix Text:
Provider Credential Text:
ANP-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
DOUGHERTY
Provider Other First Name:
DOE
Provider Other Middle Name:
CHAVONE
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
ANP-C
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1548513690
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/25/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2711 RANDOLPH ROAD
Provider Second Line Business Mailing Address:
STE 100
Provider Business Mailing Address City Name:
CHARLOTTE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28207-2027
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-342-1900
Provider Business Mailing Address Fax Number:
704-377-0353

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2711 RANDOLPH ROAD
Provider Second Line Business Practice Location Address:
STE 100
Provider Business Practice Location Address City Name:
CHARLOTTE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28207-2027
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-342-1900
Provider Business Practice Location Address Fax Number:
704-377-0353
Provider Enumeration Date:
10/25/2012

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: 363L00000X , with the licence number:  5005896 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 364SX0200X , with the licence number: 5005896 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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