Provider Demographics
NPI:1134592538
Name:VAUGHAN, BROOKES B (NP)
Entity type:Individual
Prefix:
First Name:BROOKES
Middle Name:B
Last Name:VAUGHAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2179 MADDISON AVE
Mailing Address - Street 2:
Mailing Address - City:WATKINSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30677-3171
Mailing Address - Country:US
Mailing Address - Phone:706-551-0426
Mailing Address - Fax:
Practice Address - Street 1:119 HARMONY XING STE 3
Practice Address - Street 2:
Practice Address - City:EATONTON
Practice Address - State:GA
Practice Address - Zip Code:31024-9571
Practice Address - Country:US
Practice Address - Phone:706-485-4004
Practice Address - Fax:706-262-2986
Is Sole Proprietor?:No
Enumeration Date:2015-11-06
Last Update Date:2021-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5008187363L00000X
GARN289098363LP2300X, 363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1134592538Medicaid
NCNCR183AMedicare PIN