Provider Demographics
NPI:1497164446
Name:VAUGHN, MARY (DNP, FNP-C, PMHNP-C)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:VAUGHN
Suffix:
Gender:F
Credentials:DNP, FNP-C, PMHNP-C
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP-C
Mailing Address - Street 1:3600 BLUECUTT RD STE 103
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:MS
Mailing Address - Zip Code:39705-1397
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3600 BLUECUTT RD STE 201
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:MS
Practice Address - Zip Code:39705-1397
Practice Address - Country:US
Practice Address - Phone:662-329-3973
Practice Address - Fax:662-329-9056
Is Sole Proprietor?:No
Enumeration Date:2014-08-04
Last Update Date:2025-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COAPN.0996054-NP363LA2100X
MSF0614908363LF0000X
MS2024043303363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS06330523Medicaid
MS373624YS8TMedicare PIN