Provider Demographics
NPI:1538583463
Name:DAUGHERTY, KRISTINE (PA-C)
Entity type:Individual
Prefix:
First Name:KRISTINE
Middle Name:
Last Name:DAUGHERTY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6255 CANOGA AVE APT 30
Mailing Address - Street 2:
Mailing Address - City:WOODLAND HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91367-2404
Mailing Address - Country:US
Mailing Address - Phone:804-909-9166
Mailing Address - Fax:
Practice Address - Street 1:22235 SHERMAN WAY STE 100
Practice Address - Street 2:
Practice Address - City:CANOGA PARK
Practice Address - State:CA
Practice Address - Zip Code:91303-1075
Practice Address - Country:US
Practice Address - Phone:804-909-9166
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-12
Last Update Date:2018-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA53247363A00000X
NY021203-1363A00000X
AZ6753363A00000X
IL085006234363A00000X
TXPA12195363A00000X
VA0110-006177363A00000X
CO3870363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant