MEDICARE: CAROL DOUGHERTY RN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	134708-030	WI

General Provider Information

NPI Number	:	1891048286
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CAROL DOUGHERTY RN

Provider Business Mailing Address
First Line	:	1324 MONTCLAIR PL
Second Line	:
City	:	FORT ATKINSON
State	:	WI
Zip	:	53538-1380
Country	:	US
Telephone Number	:	920-723-6602
Fax Number	:	920-568-9885

Provider Business Practice Location Address
First Line	:	1324 MONTCLAIR PL
Second Line	:
City	:	FORT ATKINSON
State	:	WI
Zip	:	53538-1380
Country	:	US
Telephone Number	:	920-723-6602
Fax Number	:	920-568-9885

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/22/2012
Last Update Date	:	10/22/2012

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