Healthcare Provider Details

I. General information

NPI: 1881945624
Provider Name (Legal Business Name): LORETTA JUNE DOUGHERTY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/19/2012
Last Update Date: 08/27/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

80 N 31ST ST
CLINTON OK
73601-9116
US

IV. Provider business mailing address

4400 N LINCOLN BLVD
OKLAHOMA CITY OK
73105-5104
US

V. Phone/Fax

Practice location:
  • Phone: 580-323-9773
  • Fax: 580-323-0828
Mailing address:
  • Phone: 580-323-9773
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: