Healthcare Provider Details

I. General information

NPI: 1376869123
Provider Name (Legal Business Name): SHANNA VAUGHAN DIAZ D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SHANNA LEIGH VAUGHAN

II. Dates (important events)

Enumeration Date: 04/19/2010
Last Update Date: 02/13/2025
Certification Date: 02/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 MEDICAL ARTS AVE NE BLDG 2
ALBUQUERQUE NM
87102-2723
US

IV. Provider business mailing address

800 BRADBURY DR SE STE 116
ALBUQUERQUE NM
87106-4310
US

V. Phone/Fax

Practice location:
  • Phone: 505-272-6110
  • Fax: 505-272-6112
Mailing address:
  • Phone: 505-272-1476
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084S0012X
TaxonomySleep Medicine (Psychiatry & Neurology) Physician
License NumberA-1690-12
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberA-1690-12
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: