MEDICARE: BRENILLA VAUGHN FNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363L00000X	Nurse Practitioner	902851	MS

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1669937611
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRENILLA VAUGHN FNP

Provider Business Mailing Address
First Line	:	747 INDUSTRIAL PARK RD NE
Second Line	:
City	:	BROOKHAVEN
State	:	MS
Zip	:	39601-2065
Country	:	US
Telephone Number	:	601-833-4111
Fax Number	:

Provider Business Practice Location Address
First Line	:	747 INDUSTRIAL PARK RD NE
Second Line	:
City	:	BROOKHAVEN
State	:	MS
Zip	:	39601-2065
Country	:	US
Telephone Number	:	601-833-4111
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/04/2019
Last Update Date	:	01/10/2023

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