Provider Demographics
NPI:1174845135
Name:DAUGHERTY, HEIDI (RN, BSN, IBCLC)
Entity type:Individual
Prefix:
First Name:HEIDI
Middle Name:
Last Name:DAUGHERTY
Suffix:
Gender:F
Credentials:RN, BSN, IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:661 ROBIN DR
Mailing Address - Street 2:
Mailing Address - City:ELLETTSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47429-1635
Mailing Address - Country:US
Mailing Address - Phone:812-361-7465
Mailing Address - Fax:
Practice Address - Street 1:661 ROBIN DR
Practice Address - Street 2:
Practice Address - City:ELLETTSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47429-1635
Practice Address - Country:US
Practice Address - Phone:812-361-7465
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-18
Last Update Date:2010-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28138372A163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant