Healthcare Provider Details

I. General information

NPI: 1720618432
Provider Name (Legal Business Name): MYRALYNN H VAUGHN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/22/2020
Last Update Date: 05/15/2025
Certification Date: 05/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 OLD DIXIE HWY
SAINT AUGUSTINE FL
32084-4190
US

IV. Provider business mailing address

13115 HARBOUR VISTA CIR
SAINT AUGUSTINE FL
32080-5104
US

V. Phone/Fax

Practice location:
  • Phone: 904-829-2273
  • Fax: 904-824-0724
Mailing address:
  • Phone: 904-615-4538
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberIMH19226
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: