Provider Demographics
NPI:1861976250
Name:POUGHT, TAWANDA (LVN)
Entity type:Individual
Prefix:
First Name:TAWANDA
Middle Name:
Last Name:POUGHT
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1503 SALTILLO PLZ
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75211-7641
Mailing Address - Country:US
Mailing Address - Phone:708-631-7825
Mailing Address - Fax:
Practice Address - Street 1:1503 SALTILLO PLZ
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75211-7641
Practice Address - Country:US
Practice Address - Phone:708-631-7825
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-20
Last Update Date:2018-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX26760164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse