Healthcare Provider Details

I. General information

NPI: 1376022376
Provider Name (Legal Business Name): KAREN VAUGHAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2018
Last Update Date: 03/14/2020
Certification Date: 03/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 TAYLOR RD
MONTGOMERY AL
36117-3512
US

IV. Provider business mailing address

2034 CHESTNUT ST
MONTGOMERY AL
36106-1111
US

V. Phone/Fax

Practice location:
  • Phone: 334-277-8330
  • Fax:
Mailing address:
  • Phone: 334-269-0212
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number1-104585
License Number StateAL
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1-104585
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: