MEDICARE: MRS. KRYSTAL HENLEY VAUGHN FNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363L00000X	Nurse Practitioner	APRN11032830	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1720606361
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KRYSTAL HENLEY VAUGHN FNP

Provider Business Mailing Address
First Line	:	PO BOX 746638
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30374-6638
Country	:	US
Telephone Number	:	904-202-2092
Fax Number	:	904-376-4075

Provider Business Practice Location Address
First Line	:	3101 UNIVERSITY BLVD S STE 102
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32216-2750
Country	:	US
Telephone Number	:	904-737-1171
Fax Number	:	904-721-4022

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/09/2020
Last Update Date	:	06/01/2026

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