Basic Information
Provider Information | |||||||||
NPI: | 1508973801 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DOUGHERTY | ||||||||
FirstName: | JUNE | ||||||||
MiddleName: | B. | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | RN | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | CARIBOU | ||||||||
OtherFirstName: | JUNE | ||||||||
OtherMiddleName: | B. | ||||||||
OtherNamePrefix: | MRS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | RN | ||||||||
OtherLastNameType: | 2 | ||||||||
Mailing Information | |||||||||
Address1: | 3600 TOWER AVE | ||||||||
Address2: | SUITE ONE | ||||||||
City: | SUPERIOR | ||||||||
State: | WI | ||||||||
PostalCode: | 548805337 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7153921955 | ||||||||
FaxNumber: | 7153921935 | ||||||||
Practice Location | |||||||||
Address1: | 3600 TOWER AVE | ||||||||
Address2: | SUITE ONE | ||||||||
City: | SUPERIOR | ||||||||
State: | WI | ||||||||
PostalCode: | 548805337 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7153921955 | ||||||||
FaxNumber: | 7153921935 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/23/2006 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WP2201X |   | WI | Y |   | Nursing Service Providers | Registered Nurse | Ambulatory Care |
No ID Information.