Provider Demographics
NPI:1851947584
Name:VAUGHN, VALENCIA L
Entity Type:Individual
Prefix:
First Name:VALENCIA
Middle Name:L
Last Name:VAUGHN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5846 RIDGEWOOD RD STE C101
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39211-2646
Mailing Address - Country:US
Mailing Address - Phone:601-213-8441
Mailing Address - Fax:
Practice Address - Street 1:5846 RIDGEWOOD RD STE C101
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39211-2646
Practice Address - Country:US
Practice Address - Phone:601-213-8441
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-19
Last Update Date:2019-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSA060372376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes376K00000XNursing Service Related ProvidersNurse's AideGroup - Single Specialty