Provider Demographics
NPI:1811353261
Name:VAUGHAN, TRACIE (NP)
Entity type:Individual
Prefix:
First Name:TRACIE
Middle Name:
Last Name:VAUGHAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 CRANBERRY RD
Mailing Address - Street 2:SUITE 200B
Mailing Address - City:GALAX
Mailing Address - State:VA
Mailing Address - Zip Code:24333-2516
Mailing Address - Country:US
Mailing Address - Phone:276-236-5187
Mailing Address - Fax:
Practice Address - Street 1:104 CRANBERRY RD
Practice Address - Street 2:SUITE 200B
Practice Address - City:GALAX
Practice Address - State:VA
Practice Address - Zip Code:24333-2516
Practice Address - Country:US
Practice Address - Phone:276-236-5187
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-14
Last Update Date:2017-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024173207363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily