Provider Demographics
NPI:1619255916
Name:VAUGHAN, HEATHER C (PT, DPT)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:C
Last Name:VAUGHAN
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:MARIE
Other - Last Name:CONROY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT, DPT
Mailing Address - Street 1:PO BOX 69030
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21264-9030
Mailing Address - Country:US
Mailing Address - Phone:757-873-2302
Mailing Address - Fax:757-873-2306
Practice Address - Street 1:3510 ANDERSON HWY STE 2
Practice Address - Street 2:
Practice Address - City:POWHATAN
Practice Address - State:VA
Practice Address - Zip Code:23139-5846
Practice Address - Country:US
Practice Address - Phone:804-598-2100
Practice Address - Fax:804-598-7624
Is Sole Proprietor?:No
Enumeration Date:2011-08-03
Last Update Date:2018-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305207012225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC05954OtherGROUP MEDICARE PTAN
VA1616255916OtherMEDICAID QMB
VAQ50403AMedicare PIN