Basic Information
| Provider Information | |||||||||
| NPI: | 1275711780 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DOUGHERTY | ||||||||
| FirstName: | PHYLLIS | ||||||||
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| Credential: | ARNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1100 CLEARWATER LARGO RD N | ||||||||
| Address2: | |||||||||
| City: | LARGO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337704131 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7275186444 | ||||||||
| FaxNumber: | 7275812678 | ||||||||
| Practice Location | |||||||||
| Address1: | 1100 CLEARWATER LARGO RD N | ||||||||
| Address2: | |||||||||
| City: | LARGO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337704131 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7275186444 | ||||||||
| FaxNumber: | 7275812678 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/06/2008 | ||||||||
| LastUpdateDate: | 06/12/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/12/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | ARNP2106712 | FL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LP0808X | ARNP2106712 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
No ID Information.