Provider Demographics
NPI:1821695578
Name:VAUGHAN, MOLLY E
Entity Type:Individual
Prefix:
First Name:MOLLY
Middle Name:E
Last Name:VAUGHAN
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 1:72 TROTTER LN
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:VA
Mailing Address - Zip Code:24538-2504
Mailing Address - Country:US
Mailing Address - Phone:434-660-0696
Mailing Address - Fax:
Practice Address - Street 1:1701 THOMSON DR
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24501-1118
Practice Address - Country:US
Practice Address - Phone:434-200-5925
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-06
Last Update Date:2020-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024180307363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology