Provider Demographics
NPI:1174299838
Name:VAUGHN, ALEXIS LILLIE
Entity Type:Individual
Prefix:
First Name:ALEXIS
Middle Name:LILLIE
Last Name:VAUGHN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ALEXIS
Other - Middle Name:LILLIE
Other - Last Name:VAUGHN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:625 S LAKE DR
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:GA
Mailing Address - Zip Code:30016-4795
Mailing Address - Country:US
Mailing Address - Phone:678-481-1439
Mailing Address - Fax:
Practice Address - Street 1:625 S LAKE DR
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:GA
Practice Address - Zip Code:30016-4795
Practice Address - Country:US
Practice Address - Phone:678-481-1439
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-20
Last Update Date:2021-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0030076692310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility