Provider Demographics
NPI:1518923093
Name:VAUGHN, RENAE (RN, MSN, ARNP-C)
Entity Type:Individual
Prefix:
First Name:RENAE
Middle Name:
Last Name:VAUGHN
Suffix:
Gender:F
Credentials:RN, MSN, ARNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 102222
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30368-2222
Mailing Address - Country:US
Mailing Address - Phone:239-274-8200
Mailing Address - Fax:
Practice Address - Street 1:61 MEMORIAL MEDICAL PKWY STE 2812
Practice Address - Street 2:
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32164-5999
Practice Address - Country:US
Practice Address - Phone:386-586-1860
Practice Address - Fax:386-586-1861
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2022-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN9495960363L00000X, 363LA2200X
SCA3669363LA2200X
MI4704167219363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL112979900Medicaid
MIN56640018Medicare PIN
P1361001Medicare PIN
0P13610Medicare PIN