=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538583463
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KRISTINE DAUGHERTY PA-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/12/2014
-----------------------------------------------------
Last Update Date | 09/19/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 22235 SHERMAN WAY STE 100
-----------------------------------------------------
City | CANOGA PARK
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91303-1075
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-909-9166
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6255 CANOGA AVE APT 30
-----------------------------------------------------
City | WOODLAND HILLS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91367-2404
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-909-9166
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | 53247
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | 021203-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | 6753
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | 085006234
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | PA12195
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #6
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | 0110-006177
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------
Taxonomy #7
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | 3870
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------