Healthcare Provider Details

I. General information

NPI: 1548513690
Provider Name (Legal Business Name): NDOME CHAVONE DOUGHERTY ANP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DOE CHAVONE DOUGHERTY ANP-C

II. Dates (important events)

Enumeration Date: 10/25/2012
Last Update Date: 10/25/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2711 RANDOLPH ROAD STE 100
CHARLOTTE NC
28207-2027
US

IV. Provider business mailing address

2711 RANDOLPH ROAD STE 100
CHARLOTTE NC
28207-2027
US

V. Phone/Fax

Practice location:
  • Phone: 704-342-1900
  • Fax: 704-377-0353
Mailing address:
  • Phone: 704-342-1900
  • Fax: 704-377-0353

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number5005896
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code364SX0200X
TaxonomyOncology Clinical Nurse Specialist
License Number5005896
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: