Healthcare Provider Details

I. General information

NPI: 1548596711
Provider Name (Legal Business Name): KRISTIN MICHELLE DAUGHERTY M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/23/2009
Last Update Date: 01/22/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1423 CHICAGO RD
CHICAGO HEIGHTS IL
60411-3400
US

IV. Provider business mailing address

121 W CHESTNUT ST 3402
CHICAGO IL
60610-3175
US

V. Phone/Fax

Practice location:
  • Phone: 708-709-1000
  • Fax:
Mailing address:
  • Phone: 304-893-8940
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code146D00000X
TaxonomyPersonal Emergency Response Attendant
License Number57.016186
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: