Provider Demographics
NPI:1508664970
Name:VAUGHN, ANETRIUS SHANTELL
Entity type:Individual
Prefix:
First Name:ANETRIUS
Middle Name:SHANTELL
Last Name:VAUGHN
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3606 S 67TH CT APT 25
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68106-4250
Mailing Address - Country:US
Mailing Address - Phone:402-714-2843
Mailing Address - Fax:402-714-2843
Practice Address - Street 1:1502 N 70TH AVE
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68104-4621
Practice Address - Country:US
Practice Address - Phone:402-714-2843
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-03
Last Update Date:2025-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes373H00000XNursing Service Related ProvidersDay Training/Habilitation Specialist