Healthcare Provider Details

I. General information

NPI: 1821695578
Provider Name (Legal Business Name): MOLLY E VAUGHAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/06/2020
Last Update Date: 10/06/2020
Certification Date: 10/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1701 THOMSON DR
LYNCHBURG VA
24501-1118
US

IV. Provider business mailing address

72 TROTTER LN
CONCORD VA
24538-2504
US

V. Phone/Fax

Practice location:
  • Phone: 434-200-5925
  • Fax:
Mailing address:
  • Phone: 434-660-0696
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number0024180307
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: