Healthcare Provider Details

I. General information

NPI: 1699324228
Provider Name (Legal Business Name): ANDREA DOHERTY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/06/2019
Last Update Date: 12/13/2021
Certification Date: 12/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

262 W MAIN ST
AMELIA OH
45102-1309
US

IV. Provider business mailing address

2620 ELM HILL PIKE
NASHVILLE TN
37214-3108
US

V. Phone/Fax

Practice location:
  • Phone: 513-718-2260
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAPRN.CNP.0030124
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code363LS0200X
TaxonomySchool Nurse Practitioner
License NumberRN.412791
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0030124
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: