Basic Information
| Provider Information | |||||||||
| NPI: | 1851991194 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DOHERTY | ||||||||
| FirstName: | KATELYN | ||||||||
| MiddleName: | ALYSSA | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5 EVA LN | ||||||||
| Address2: | |||||||||
| City: | FARMINGVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117381010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6316247943 | ||||||||
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| Practice Location | |||||||||
| Address1: | 45 RESEARCH WAY STE 108 | ||||||||
| Address2: | |||||||||
| City: | EAST SETAUKET | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117336401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6319412000 | ||||||||
| FaxNumber: | 6319412010 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/27/2020 | ||||||||
| LastUpdateDate: | 11/02/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | F309820-01 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.