Provider Demographics
NPI:1881801132
Name:VAUGHAN, IVA NELL (FNP)
Entity type:Individual
Prefix:MS
First Name:IVA
Middle Name:NELL
Last Name:VAUGHAN
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2101 HIGHWAY 90
Mailing Address - Street 2:
Mailing Address - City:GAUTIER
Mailing Address - State:MS
Mailing Address - Zip Code:39553-5340
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:22A DOCTORS DR
Practice Address - Street 2:
Practice Address - City:OCEAN SPRINGS
Practice Address - State:MS
Practice Address - Zip Code:39564-5721
Practice Address - Country:US
Practice Address - Phone:228-872-1951
Practice Address - Fax:228-875-9998
Is Sole Proprietor?:No
Enumeration Date:2007-05-17
Last Update Date:2013-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR753601363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSC00047OtherMEDICARE GROUP #
MS05078304Medicaid
MS09014182OtherMEDICAID GROUP #
646000515OtherBLUE CROSS OF MS
646000515OtherTRICARE
500028696OtherRAILROAD MEDICARE