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
State | License ID | Taxonomies |
---|---|---|
VA | 2305207012 | 225100000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 225100000X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
VA | C05954 | Other | GROUP MEDICARE PTAN |
VA | 1616255916 | Other | MEDICAID QMB |
VA | Q50403A | Medicare PIN |