Healthcare Provider Details

I. General information

NPI: 1063334738
Provider Name (Legal Business Name): DAVID EDWARD VAUGHN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/27/2026
Last Update Date: 07/27/2026
Certification Date: 07/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 SAINT LOUIS AVE
BRISTOL TN
37620-5206
US

IV. Provider business mailing address

105 SAINT LOUIS AVE
BRISTOL TN
37620-5206
US

V. Phone/Fax

Practice location:
  • Phone: 423-742-1667
  • Fax:
Mailing address:
  • Phone: 423-742-1667
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number42495
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: