Healthcare Provider Details

I. General information

NPI: 1285909572
Provider Name (Legal Business Name): KATHLEEN CHRISTINA DOHERTY REGISTERED NURSE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2012
Last Update Date: 03/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

212 N MAIN ST
MONROE NY
10950-2845
US

IV. Provider business mailing address

212 N MAIN ST
MONROE NY
10950-2845
US

V. Phone/Fax

Practice location:
  • Phone: 845-460-6800
  • Fax: 845-460-6038
Mailing address:
  • Phone: 845-460-6800
  • Fax: 845-460-6038

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License Number22454430
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: