=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134470891
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GERALDINE M DOUGHERTY R.N.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/20/2012
-----------------------------------------------------
Last Update Date | 09/20/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 190 WASHINGTON AVE
-----------------------------------------------------
City | BATAVIA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14020-2113
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 585-344-1227
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6043 MAIN RD
-----------------------------------------------------
City | STAFFORD
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14143-9519
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 585-330-1462
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 364S00000X
-----------------------------------------------------
Taxonomy Name | Clinical Nurse Specialist
-----------------------------------------------------
License Number | 131069-J
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------