Healthcare Provider Details

I. General information

NPI: 1477483865
Provider Name (Legal Business Name): IVY ELIZABETH VAGOTT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2026
Last Update Date: 05/19/2026
Certification Date: 05/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

699 HOWARD HOLW
WILLIAMSON WV
25661-6857
US

IV. Provider business mailing address

699 HOWARD HOLW
WILLIAMSON WV
25661-6857
US

V. Phone/Fax

Practice location:
  • Phone: 304-785-0251
  • Fax:
Mailing address:
  • Phone: 304-785-0251
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number274124
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: