Healthcare Provider Details

I. General information

NPI: 1053706556
Provider Name (Legal Business Name): ZACHARY VAUGH NP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/01/2015
Last Update Date: 05/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1078 EAGLE VALLEY DR
FESTUS MO
63028-1257
US

IV. Provider business mailing address

1078 EAGLE VALLEY DR
FESTUS MO
63028-1257
US

V. Phone/Fax

Practice location:
  • Phone: 314-488-3464
  • Fax:
Mailing address:
  • Phone: 314-488-3464
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberAG1214019
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAG1214019
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: