Provider Demographics
NPI:1447706502
Name:DAUGHERTY, JENIELLE (FNP)
Entity type:Individual
Prefix:
First Name:JENIELLE
Middle Name:
Last Name:DAUGHERTY
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4100 BRIARGATE PARKWAY
Mailing Address - Street 2:SUITE #300
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80920
Mailing Address - Country:US
Mailing Address - Phone:719-632-7669
Mailing Address - Fax:
Practice Address - Street 1:4100 BRIARGATE PARKWAY
Practice Address - Street 2:SUITE #300
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80920
Practice Address - Country:US
Practice Address - Phone:719-632-7669
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-29
Last Update Date:2016-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0992438364SF0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SF0001XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistFamily Health