=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083414882
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | EMILY JANE VAUGHN PA-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/19/2025
-----------------------------------------------------
Last Update Date | 11/12/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 934 S BROADWAY ST STE C
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37148-1718
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 615-325-6446
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3024 BUSINESS PARK CIR
-----------------------------------------------------
City | GOODLETTSVILLE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37072-3132
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 615-239-2018
-----------------------------------------------------
Fax | 615-850-2018
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------