Healthcare Provider Details

I. General information

NPI: 1710294145
Provider Name (Legal Business Name): AMANDA VAUGHN DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2010
Last Update Date: 09/07/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

551 S HIGLEY RD
MESA AZ
85206-2148
US

IV. Provider business mailing address

551 S HIGLEY RD
MESA AZ
85206-2148
US

V. Phone/Fax

Practice location:
  • Phone: 480-892-9777
  • Fax: 480-635-0222
Mailing address:
  • Phone: 480-892-9777
  • Fax: 480-635-0222

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number7769
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number7769
License Number StateAZ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: