Provider Demographics
NPI:1730329061
Name:JABALI-VAUGHN, IMANI NADIR (PTA)
Entity type:Individual
Prefix:MRS
First Name:IMANI
Middle Name:NADIR
Last Name:JABALI-VAUGHN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12158 CENTRAL AVE STE 215
Mailing Address - Street 2:
Mailing Address - City:MITCHELLVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20721-1932
Mailing Address - Country:US
Mailing Address - Phone:301-390-3076
Mailing Address - Fax:
Practice Address - Street 1:3833 FAIRFAX DR
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:VA
Practice Address - Zip Code:22203-1772
Practice Address - Country:US
Practice Address - Phone:301-540-6140
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-02-26
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2306602647225200000X
MDA3373225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant