Provider Demographics
NPI:1003084336
Name:VAUGHN, RENATA JANE (APN, FNP)
Entity Type:Individual
Prefix:MRS
First Name:RENATA
Middle Name:JANE
Last Name:VAUGHN
Suffix:
Gender:F
Credentials:APN, FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 497
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:AR
Mailing Address - Zip Code:72006-0497
Mailing Address - Country:US
Mailing Address - Phone:870-347-2534
Mailing Address - Fax:870-347-3492
Practice Address - Street 1:1530 N CHURCH ST
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-1515
Practice Address - Country:US
Practice Address - Phone:870-802-3590
Practice Address - Fax:870-327-7970
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-20
Last Update Date:2013-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA003060363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR195346758Medicaid
AR57297Medicare PIN
AR195346758Medicaid