Healthcare Provider Details

I. General information

NPI: 1518582139
Provider Name (Legal Business Name): BRIDGETTE L VAUGHN NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/09/2020
Last Update Date: 05/29/2026
Certification Date: 05/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

408 FLAGSTONE DR
BELLEVILLE IL
62221-5824
US

IV. Provider business mailing address

408 FLAGSTONE DR
BELLEVILLE IL
62221-5824
US

V. Phone/Fax

Practice location:
  • Phone: 618-304-2333
  • Fax:
Mailing address:
  • Phone: 618-304-2333
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number277002949
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: