Basic Information
| Provider Information | |||||||||
| NPI: | 1295708774 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DOUGHERTY | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | E. | ||||||||
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| Credential: | NP-CNM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 535 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | OLEAN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 14760 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7163720141 | ||||||||
| FaxNumber: | 7163726421 | ||||||||
| Practice Location | |||||||||
| Address1: | 535 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | OLEAN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 14760 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7163720141 | ||||||||
| FaxNumber: | 7163726421 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/07/2006 | ||||||||
| LastUpdateDate: | 06/15/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LW0102X | F420192 | NY | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Women's Health | 367A00000X | F000461 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife |
ID Information
| ID | Type | State | Issuer | Description | 01436364 | 05 | NY | MEDICAID |