Healthcare Provider Details

I. General information

NPI: 1689210791
Provider Name (Legal Business Name): ALEXIS TIERRA VAUGHN CMM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MS. ALEXIS TIERRA SMALLS

II. Dates (important events)

Enumeration Date: 11/24/2019
Last Update Date: 12/23/2024
Certification Date: 12/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4420 BOSTIC DR APT 306
GREENVILLE NC
27834-9423
US

IV. Provider business mailing address

4420 BOSTIC DR APT 306
GREENVILLE NC
27834-9423
US

V. Phone/Fax

Practice location:
  • Phone: 229-379-8873
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: