Provider Demographics
NPI:1376900563
Name:VAUGHAN, COURTNEY (PA)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:
Last Name:VAUGHAN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:COURTNEY
Other - Middle Name:
Other - Last Name:BROOKS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:2406 LIGHTHOUSE MANOR DR
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30501-7401
Mailing Address - Country:US
Mailing Address - Phone:770-536-4352
Mailing Address - Fax:770-532-8165
Practice Address - Street 1:2406 LIGHTHOUSE MANOR DR
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-7401
Practice Address - Country:US
Practice Address - Phone:770-536-4352
Practice Address - Fax:770-532-8165
Is Sole Proprietor?:No
Enumeration Date:2016-01-20
Last Update Date:2017-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA7851363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant