Provider Demographics
NPI:1629114756
Name:VAUGHN, ANGELA DALE (MS, RD, LD)
Entity Type:Individual
Prefix:MRS
First Name:ANGELA
Middle Name:DALE
Last Name:VAUGHN
Suffix:
Gender:F
Credentials:MS, RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 SCHNEIDER DR
Mailing Address - Street 2:
Mailing Address - City:MALVERN
Mailing Address - State:AR
Mailing Address - Zip Code:72104-4811
Mailing Address - Country:US
Mailing Address - Phone:507-332-1064
Mailing Address - Fax:501-332-7054
Practice Address - Street 1:806 GLENDALE ST
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-4455
Practice Address - Country:US
Practice Address - Phone:870-933-9528
Practice Address - Fax:870-933-9778
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2019-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR726133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered