Provider Demographics
NPI:1306006929
Name:VAUGHN, SHANNON R (NP)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:R
Last Name:VAUGHN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:190 E BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6241
Mailing Address - Country:US
Mailing Address - Phone:208-336-4141
Mailing Address - Fax:
Practice Address - Street 1:300 E JEFFERSON ST
Practice Address - Street 2:SUITE 101
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83712-6246
Practice Address - Country:US
Practice Address - Phone:208-322-1680
Practice Address - Fax:208-685-2282
Is Sole Proprietor?:No
Enumeration Date:2008-06-17
Last Update Date:2012-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNP870A363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID20000917Medicare PIN