Provider Demographics
NPI:1447723374
Name:DAUGHERTY, TYLER
Entity type:Individual
Prefix:
First Name:TYLER
Middle Name:
Last Name:DAUGHERTY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2374 RIVER RUN TRCE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43235-4995
Mailing Address - Country:US
Mailing Address - Phone:937-481-1931
Mailing Address - Fax:
Practice Address - Street 1:765 PIERCE DR
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43223-2425
Practice Address - Country:US
Practice Address - Phone:614-233-1650
Practice Address - Fax:888-679-9808
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-03
Last Update Date:2019-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN.447202163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse