Healthcare Provider Details

I. General information

NPI: 1720606361
Provider Name (Legal Business Name): KRYSTAL HENLEY VAUGHN FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KRYSTAL HENLEY

II. Dates (important events)

Enumeration Date: 07/09/2020
Last Update Date: 04/29/2026
Certification Date: 04/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121 W MACCLENNY AVE
MACCLENNY FL
32063-2029
US

IV. Provider business mailing address

PO BOX 746638
ATLANTA GA
30374-6638
US

V. Phone/Fax

Practice location:
  • Phone: 904-259-6380
  • Fax:
Mailing address:
  • Phone: 904-202-2092
  • Fax: 904-376-4075

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAPRN11032830
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: