Healthcare Provider Details

I. General information

NPI: 1851715437
Provider Name (Legal Business Name): REBECCA VAUGHAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/18/2014
Last Update Date: 02/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

933 BRADBURY DR SE STE 2222
ALBUQUERQUE NM
87106-4375
US

IV. Provider business mailing address

6701 VISTA DEL SOL DR NW
ALBUQUERQUE NM
87120-3798
US

V. Phone/Fax

Practice location:
  • Phone: 505-272-3120
  • Fax: 505-272-8060
Mailing address:
  • Phone: 505-899-0487
  • Fax: 505-272-4549

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberCNP-02322
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: