Healthcare Provider Details

I. General information

NPI: 1134231541
Provider Name (Legal Business Name): GENIE B VAUGHAN RN, CFNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: GENIE B RUSSELL RN, CFNP

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1065 E BROAD ST
MONTICELLO MS
39654-7703
US

IV. Provider business mailing address

179 TOM SISTRUNK RD
JAYESS MS
39641-3781
US

V. Phone/Fax

Practice location:
  • Phone: 601-587-4051
  • Fax: 601-587-1256
Mailing address:
  • Phone: 601-587-2678
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR776769
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: