Provider Demographics
NPI:1720618432
Name:VAUGHN, MYRALYNN H
Entity Type:Individual
Prefix:
First Name:MYRALYNN
Middle Name:H
Last Name:VAUGHN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13115 HARBOUR VISTA CIR
Mailing Address - Street 2:
Mailing Address - City:SAINT AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32080-5104
Mailing Address - Country:US
Mailing Address - Phone:904-615-4538
Mailing Address - Fax:
Practice Address - Street 1:248 SOUTHPARK CIR E
Practice Address - Street 2:
Practice Address - City:SAINT AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-5137
Practice Address - Country:US
Practice Address - Phone:904-797-5680
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-22
Last Update Date:2020-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH19226101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health