Provider Demographics
NPI:1053931949
Name:DOUGHERTY, AMY LYNN
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:LYNN
Last Name:DOUGHERTY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 TILGHMAN DR
Mailing Address - Street 2:
Mailing Address - City:DUNN
Mailing Address - State:NC
Mailing Address - Zip Code:28334-5891
Mailing Address - Country:US
Mailing Address - Phone:910-892-6500
Mailing Address - Fax:
Practice Address - Street 1:110 TRADERS CROSS FL 1
Practice Address - Street 2:
Practice Address - City:BLUFFTON
Practice Address - State:SC
Practice Address - Zip Code:29909-4637
Practice Address - Country:US
Practice Address - Phone:877-564-3627
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-21
Last Update Date:2024-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC25798363LF0000X
NC5013327363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily