Provider Demographics
NPI:1003506379
Name:MURRAY, LAVAUGHN
Entity Type:Individual
Prefix:
First Name:LAVAUGHN
Middle Name:
Last Name:MURRAY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1660 GRAYS RD
Mailing Address - Street 2:
Mailing Address - City:PORT REPUBLIC
Mailing Address - State:MD
Mailing Address - Zip Code:20676-2146
Mailing Address - Country:US
Mailing Address - Phone:301-455-5054
Mailing Address - Fax:
Practice Address - Street 1:1660 GRAYS RD
Practice Address - Street 2:
Practice Address - City:PORT REPUBLIC
Practice Address - State:MD
Practice Address - Zip Code:20676-2146
Practice Address - Country:US
Practice Address - Phone:301-455-5054
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-10
Last Update Date:2023-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDM600488469244172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172A00000XOther Service ProvidersDriverGroup - Single Specialty