Healthcare Provider Details

I. General information

NPI: 1588185888
Provider Name (Legal Business Name): DIANA VAUGHN FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DIANA MUGGE FNP-C

II. Dates (important events)

Enumeration Date: 06/28/2017
Last Update Date: 01/13/2023
Certification Date: 01/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1112 OAK ST STE 102
CARMI IL
62821-1344
US

IV. Provider business mailing address

PO BOX 429
MC LEANSBORO IL
62859-0429
US

V. Phone/Fax

Practice location:
  • Phone: 618-382-5985
  • Fax: 855-827-3536
Mailing address:
  • Phone: 618-643-2361
  • Fax: 618-643-2502

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number041290795
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209.016082
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: