Basic Information
| Provider Information | |||||||||
| NPI: | 1396019634 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DAUGHERTY | ||||||||
| FirstName: | CHANNIN | ||||||||
| MiddleName: | D | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 PASTEUR DR | ||||||||
| Address2: | |||||||||
| City: | STANFORD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 943052200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6507234000 | ||||||||
| FaxNumber: | 6504985840 | ||||||||
| Practice Location | |||||||||
| Address1: | 21 CORPORATE WOODS | ||||||||
| Address2: | 10870 BENSON DRIVE #2160 | ||||||||
| City: | OVERLAND PARK | ||||||||
| State: | KS | ||||||||
| PostalCode: | 662106621 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8333573227 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/05/2012 | ||||||||
| LastUpdateDate: | 01/29/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 3007357 | KY | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363L00000X | 23205 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.