Basic Information
| Provider Information | |||||||||
| NPI: | 1609392117 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DOUGHERTY | ||||||||
| FirstName: | COLLEEN | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | CRNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 836 N IRVING AVE | ||||||||
| Address2: | |||||||||
| City: | SCRANTON | ||||||||
| State: | PA | ||||||||
| PostalCode: | 18510 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5703357222 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5 S WASHINGTON AVE | ||||||||
| Address2: | |||||||||
| City: | JERMYN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 184331121 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5702300019 | ||||||||
| FaxNumber: | 2702300013 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2017 | ||||||||
| LastUpdateDate: | 12/10/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | SP017680 | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.