Provider Demographics
NPI:1942336227
Name:VAUGHN, LISA LEIGH (PTA)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:LEIGH
Last Name:VAUGHN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2602 S 18TH ST
Mailing Address - Street 2:
Mailing Address - City:PARAGOULD
Mailing Address - State:AR
Mailing Address - Zip Code:72450-5830
Mailing Address - Country:US
Mailing Address - Phone:870-215-8012
Mailing Address - Fax:870-240-8505
Practice Address - Street 1:1910 RECTOR RD
Practice Address - Street 2:
Practice Address - City:PARAGOULD
Practice Address - State:AR
Practice Address - Zip Code:72450-2004
Practice Address - Country:US
Practice Address - Phone:870-240-8500
Practice Address - Fax:870-240-8505
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPTA1595225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant