Basic Information
| Provider Information | |||||||||
| NPI: | 1639331630 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAUGHARTHY | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | LAUREN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4358 MELROSE ABBEY PLACE | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 89141 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3107025538 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 9300 W SUNSET RD | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891484844 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9729153600 | ||||||||
| FaxNumber: | 9729153636 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2008 | ||||||||
| LastUpdateDate: | 07/20/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 13239 | NV | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 13239 | 01 | NV | NV MEDICAL LICENSE | OTHER | CS18202 | 01 | NV | PHARMACY/CONTROLLED SUBSTANCE CERTIFICATE | OTHER | FD0620838 | 01 | NV | DEA | OTHER |