Healthcare Provider Details

I. General information

NPI: 1053931949
Provider Name (Legal Business Name): AMY LYNN DOUGHERTY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/21/2020
Last Update Date: 12/03/2024
Certification Date: 12/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 TRADERS CROSS FL 1
BLUFFTON SC
29909-4637
US

IV. Provider business mailing address

801 TILGHMAN DR
DUNN NC
28334-5891
US

V. Phone/Fax

Practice location:
  • Phone: 877-564-3627
  • Fax:
Mailing address:
  • Phone: 910-892-6500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number25798
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number5013327
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: