Healthcare Provider Details

I. General information

NPI: 1972647568
Provider Name (Legal Business Name): DAWNIAL VAUGHAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/16/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26317 W WASHINGTON ST
PETERSBURG VA
23803
US

IV. Provider business mailing address

24010 BANCROFT DR
PETERSBURG VA
23803-8437
US

V. Phone/Fax

Practice location:
  • Phone: 804-524-7346
  • Fax:
Mailing address:
  • Phone: 804-733-4306
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License Number0230006557
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: