1669792016 NPI number — CHARITA LEEANNE DAUGHERTY STNA

Table of content: CHARITA LEEANNE DAUGHERTY STNA (NPI 1669792016)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669792016 NPI number — CHARITA LEEANNE DAUGHERTY STNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DAUGHERTY
Provider First Name:
CHARITA
Provider Middle Name:
LEEANNE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
STNA
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:
1669792016
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/08/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1100 THORNWOOD DR
Provider Second Line Business Mailing Address:
LOT 78
Provider Business Mailing Address City Name:
HEATH
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
43056-9500
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
740-281-0028
Provider Business Mailing Address Fax Number:
740-281-0028

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1100 THORNWOOD DR
Provider Second Line Business Practice Location Address:
LOT 78
Provider Business Practice Location Address City Name:
HEATH
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
43056-9500
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
740-281-0028
Provider Business Practice Location Address Fax Number:
740-281-0028
Provider Enumeration Date:
06/08/2010

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: 376K00000X , with the licence number:  374494460195 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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