Provider Demographics
NPI:1447905609
Name:DAUGHERTY, BRENDA L
Entity type:Individual
Prefix:
First Name:BRENDA
Middle Name:L
Last Name:DAUGHERTY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1550 2ND AVE SPC 6A
Mailing Address - Street 2:
Mailing Address - City:GOLD HILL
Mailing Address - State:OR
Mailing Address - Zip Code:97525-9728
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1550 2ND AVE SPC 6A
Practice Address - Street 2:
Practice Address - City:GOLD HILL
Practice Address - State:OR
Practice Address - Zip Code:97525-9728
Practice Address - Country:US
Practice Address - Phone:541-728-8428
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-16
Last Update Date:2022-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide