Healthcare Provider Details

I. General information

NPI: 1225949498
Provider Name (Legal Business Name): ANGELA NYCOLE VAUGHN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/15/2026
Last Update Date: 09/25/2026
Certification Date: 09/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4201 BRIDGEVIEW DR
FORT WORTH TX
76109-9571
US

IV. Provider business mailing address

9056 SUMMIT PENINSULA RD APT 5107
FORT WORTH TX
76123-2384
US

V. Phone/Fax

Practice location:
  • Phone: 817-369-3092
  • Fax:
Mailing address:
  • Phone: 318-820-8200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-26-2848219
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: