Healthcare Provider Details

I. General information

NPI: 1295189231
Provider Name (Legal Business Name): KATELYN VAUGHAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/15/2016
Last Update Date: 02/23/2023
Certification Date: 02/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10310 W MARKHAM ST STE 205
LITTLE ROCK AR
72205-1579
US

IV. Provider business mailing address

10702 CRESTDALE LN
LITTLE ROCK AR
72212-3624
US

V. Phone/Fax

Practice location:
  • Phone: 501-406-7910
  • Fax: 501-251-1099
Mailing address:
  • Phone: 870-338-0579
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number3917
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number4154
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: