Healthcare Provider Details

I. General information

NPI: 1083387369
Provider Name (Legal Business Name): KATELYNN GENEVIEVE DOUGHERTY SOPER DNP, FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2021
Last Update Date: 08/01/2021
Certification Date: 06/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

227 SAINT PAUL ST
BALTIMORE MD
21202-2001
US

IV. Provider business mailing address

13 PATCHWORK CT
MONKTON MD
21111-1604
US

V. Phone/Fax

Practice location:
  • Phone: 410-783-5858
  • Fax:
Mailing address:
  • Phone: 443-829-9609
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR192850
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: