Provider Demographics
NPI:1194199448
Name:CHERRY-VAUGHN, KIM
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:
Last Name:CHERRY-VAUGHN
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:PO BOX 13354
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23325-0354
Mailing Address - Country:US
Mailing Address - Phone:757-289-5810
Mailing Address - Fax:
Practice Address - Street 1:2709 CAMPOSTELLA RD
Practice Address - Street 2:SUITES I AND J
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23324-3604
Practice Address - Country:US
Practice Address - Phone:757-289-5810
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-24
Last Update Date:2015-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001223130163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse