Healthcare Provider Details

I. General information

NPI: 1336813252
Provider Name (Legal Business Name): BAILEY MARIE DAUGHERTY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2021
Last Update Date: 12/05/2023
Certification Date: 09/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

595 N BROADWAY AVE
HYDRO OK
73048-8425
US

IV. Provider business mailing address

76642 N 2580 RD
WATONGA OK
73772
US

V. Phone/Fax

Practice location:
  • Phone: 833-274-4174
  • Fax: 866-274-4175
Mailing address:
  • Phone: 580-791-3280
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number204967
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR0117295
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: