Healthcare Provider Details

I. General information

NPI: 1609108265
Provider Name (Legal Business Name): DIANE ELAINE DOHERTY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: DIANE ELAINE EMLEY L.V.N.

II. Dates (important events)

Enumeration Date: 02/08/2010
Last Update Date: 02/08/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9098 W RIDGE LINE LN
COEUR D ALENE ID
83814-9103
US

IV. Provider business mailing address

9098 W. RIDGE LINE
COEUR D ALENE ID
83814-9103
US

V. Phone/Fax

Practice location:
  • Phone: 208-651-2186
  • Fax: 208-769-7960
Mailing address:
  • Phone: 208-651-2186
  • Fax: 208-769-7960

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License Number
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License NumberVN 3801
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: