Basic Information
| Provider Information | |||||||||
| NPI: | 1730104837 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DOUGHERTY | ||||||||
| FirstName: | DEBRA | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | ARNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2234 COLONIAL BLVD | ||||||||
| Address2: | ATTN: PAYER CONTRACTING & RELATIONS DEPT. | ||||||||
| City: | FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339071412 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2399317342 | ||||||||
| FaxNumber: | 2399317385 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 3RD AVE W | ||||||||
| Address2: | SUITE 210 | ||||||||
| City: | BRADENTON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342058626 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9417920340 | ||||||||
| FaxNumber: | 9417942251 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2006 | ||||||||
| LastUpdateDate: | 04/02/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 71001790 | IN | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LW0102X | 2258P | KY | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Women's Health | 363LW0102X | 9338893 | FL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Women's Health | 363L00000X | ARNP9338893 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 2447974000 | 01 | KY | PASSPORT ADVANTAGE | OTHER | 7663234 | 01 | AETNA | OTHER | 78001427 | 05 | KY | MEDICAID | P01420776 | 01 | FL | RR MEDICARE | OTHER | 070134 | 01 | IN | SIHO | OTHER | 000000381896 | 01 | IN | ANTHEM BCBS | OTHER | 200404560 | 05 | IN | MEDICAID | 50006753 | 01 | KY | PASSPORT KY MEDICAID | OTHER | Y0C29 | 01 | FL | BCBS | OTHER |