Healthcare Provider Details

I. General information

NPI: 1528651825
Provider Name (Legal Business Name): ANITA L. VAUGHN II
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/17/2021
Last Update Date: 06/03/2021
Certification Date: 06/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1451 ROBERTS RD
MEMPHIS TN
38106-6938
US

IV. Provider business mailing address

1451 ROBERTS RD
MEMPHIS TN
38106-6938
US

V. Phone/Fax

Practice location:
  • Phone: 901-406-3759
  • Fax:
Mailing address:
  • Phone: 901-406-3759
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code347E00000X
TaxonomyTransportation Broker
License Number
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: