Healthcare Provider Details

I. General information

NPI: 1366436685
Provider Name (Legal Business Name): ELIZABETH ANN VAUGHT MS, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ELIZABETH ANN ST. GEORGE

II. Dates (important events)

Enumeration Date: 08/31/2005
Last Update Date: 09/07/2021
Certification Date: 09/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5114 N CHARLES ST
BALTIMORE MD
21210-2021
US

IV. Provider business mailing address

6 SOUTHWORTH CT
BEL AIR MD
21014-4508
US

V. Phone/Fax

Practice location:
  • Phone: 410-649-3315
  • Fax:
Mailing address:
  • Phone: 410-638-9707
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberA0000176
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: