Healthcare Provider Details

I. General information

NPI: 1669466074
Provider Name (Legal Business Name): PATRICIA M VAUGHN-GOODMAN APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2005
Last Update Date: 12/14/2021
Certification Date: 12/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 LITTLE MOUNTAIN RD
NINETY SIX SC
29666-9252
US

IV. Provider business mailing address

103 LITTLE MOUNTAIN RD
NINETY SIX SC
29666-9252
US

V. Phone/Fax

Practice location:
  • Phone: 864-543-3515
  • Fax: 864-543-2973
Mailing address:
  • Phone: 864-543-3515
  • Fax: 864-543-2973

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1951
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: