Provider Demographics
NPI:1548513690
Name:DOUGHERTY, NDOME CHAVONE (ANP-C)
Entity type:Individual
Prefix:MISS
First Name:NDOME
Middle Name:CHAVONE
Last Name:DOUGHERTY
Suffix:
Gender:F
Credentials:ANP-C
Other - Prefix:MISS
Other - First Name:DOE
Other - Middle Name:CHAVONE
Other - Last Name:DOUGHERTY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:ANP-C
Mailing Address - Street 1:2711 RANDOLPH ROAD
Mailing Address - Street 2:STE 100
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28207-2027
Mailing Address - Country:US
Mailing Address - Phone:704-342-1900
Mailing Address - Fax:704-377-0353
Practice Address - Street 1:2711 RANDOLPH ROAD
Practice Address - Street 2:STE 100
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28207-2027
Practice Address - Country:US
Practice Address - Phone:704-342-1900
Practice Address - Fax:704-377-0353
Is Sole Proprietor?:No
Enumeration Date:2012-10-25
Last Update Date:2012-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5005896363L00000X, 364SX0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No364SX0200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistOncology