Provider Demographics
NPI:1134231541
Name:VAUGHAN, GENIE B (RN, CFNP)
Entity type:Individual
Prefix:
First Name:GENIE
Middle Name:B
Last Name:VAUGHAN
Suffix:
Gender:F
Credentials:RN, CFNP
Other - Prefix:
Other - First Name:GENIE
Other - Middle Name:B
Other - Last Name:RUSSELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN, CFNP
Mailing Address - Street 1:179 TOM SISTRUNK RD
Mailing Address - Street 2:
Mailing Address - City:JAYESS
Mailing Address - State:MS
Mailing Address - Zip Code:39641-3781
Mailing Address - Country:US
Mailing Address - Phone:601-587-2678
Mailing Address - Fax:
Practice Address - Street 1:1065 E BROAD ST
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:MS
Practice Address - Zip Code:39654-7703
Practice Address - Country:US
Practice Address - Phone:601-587-4051
Practice Address - Fax:601-587-1256
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR776769363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00124884Medicaid
MS00124884Medicaid