Healthcare Provider Details

I. General information

NPI: 1932019098
Provider Name (Legal Business Name): KELLY MIMS DOUGHERTY LM, CPM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/10/2026
Last Update Date: 09/10/2026
Certification Date: 09/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1210 AVE G
OLTON TX
79064-0831
US

IV. Provider business mailing address

PO BOX 831
OLTON TX
79064-0831
US

V. Phone/Fax

Practice location:
  • Phone: 325-812-1558
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code176B00000X
TaxonomyMidwife
License Number99622
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: