Provider Demographics
NPI:1205986122
Name:VAUGHN, AUDREY ELIZABETH I
Entity type:Individual
Prefix:
First Name:AUDREY
Middle Name:ELIZABETH
Last Name:VAUGHN
Suffix:I
Gender:F
Credentials:
Other - Prefix:
Other - First Name:AUDREY
Other - Middle Name:ELIZABETH
Other - Last Name:STONE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3960 NEW COVINGTON PIKE
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38128-2504
Mailing Address - Country:US
Mailing Address - Phone:901-516-5320
Mailing Address - Fax:901-516-5099
Practice Address - Street 1:3960 NEW COVINGTON PIKE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38128-2504
Practice Address - Country:US
Practice Address - Phone:901-516-5320
Practice Address - Fax:901-516-5099
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2020-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT227892251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL891782500Medicaid