Healthcare Provider Details

I. General information

NPI: 1164347829
Provider Name (Legal Business Name): MARISA VAUGHN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2026
Last Update Date: 08/12/2026
Certification Date: 08/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3347 MASONIC DR
ALEXANDRIA LA
71301-3842
US

IV. Provider business mailing address

2145 HORSESHOE DR APT 6133
ALEXANDRIA LA
71301-2028
US

V. Phone/Fax

Practice location:
  • Phone: 318-466-6111
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number08856
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: