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General NPI Number Information
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NPI Number | 1992990238
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Entity Type | Individual
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Provider Name | WALLISA TEJARNETTE VAUGHN M.D.
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Gender | Female
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Dates
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Enumeration Date | 09/10/2007
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Last Update Date | 01/24/2025
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Provider Practice Location Address
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Address Line | 850 KEMPSVILLE RD STE 200A
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City | NORFOLK
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State | VA
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Zip | 23502-3920
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Country | US
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Telephone | 757-261-5910
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Fax |
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Provider Business Mailing Address
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Address Line | 5060 VALLEY VIEW BLVD NW
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City | ROANOKE
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State | VA
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Zip | 24012-2038
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Country | US
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Telephone | 540-278-1051
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 0101255299
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License Number State | VA
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