Provider Demographics
NPI:1013584663
Name:VAUGHN, VEORNA NICHOLE (N/A)
Entity Type:Individual
Prefix:MRS
First Name:VEORNA
Middle Name:NICHOLE
Last Name:VAUGHN
Suffix:
Gender:F
Credentials:N/A
Other - Prefix:MISS
Other - First Name:VEORNA
Other - Middle Name:NICHOLE
Other - Last Name:JONES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:N/A
Mailing Address - Street 1:650 PONCE DE LEON AVE NE STE 300
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30308-1864
Mailing Address - Country:US
Mailing Address - Phone:404-468-4710
Mailing Address - Fax:
Practice Address - Street 1:1356 TRAE LN STE 419
Practice Address - Street 2:
Practice Address - City:LITHIA SPRINGS
Practice Address - State:GA
Practice Address - Zip Code:30122-3235
Practice Address - Country:US
Practice Address - Phone:404-468-4710
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-10
Last Update Date:2021-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
335E00000X
TX1535401335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000000OtherN/A