MEDICARE: MRS. CHARLENE LUECINDA VAUGHAN NP

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	363LF0000X	Family Nurse Practitioner	R778046	MS

General Provider Information

NPI Number	:	1790035731
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. CHARLENE LUECINDA VAUGHAN NP

Provider Business Mailing Address
First Line	:	111 ALABAMA ST
Second Line	:
City	:	COLUMBUS
State	:	MS
Zip	:	39702-5220
Country	:	US
Telephone Number	:	662-570-4636
Fax Number	:	662-798-0191

Provider Business Practice Location Address
First Line	:	111 ALABAMA ST
Second Line	:
City	:	COLUMBUS
State	:	MS
Zip	:	39702-5220
Country	:	US
Telephone Number	:	662-570-4636
Fax Number	:	662-798-0191

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

Provider Enumeration Date	:	09/18/2012
Last Update Date	:	08/02/2024

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