Basic Information
| Provider Information | |||||||||
| NPI: | 1881801132 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VAUGHAN | ||||||||
| FirstName: | IVA | ||||||||
| MiddleName: | NELL | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2101 HIGHWAY 90 | ||||||||
| Address2: | |||||||||
| City: | GAUTIER | ||||||||
| State: | MS | ||||||||
| PostalCode: | 395535340 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 22A DOCTORS DR | ||||||||
| Address2: | |||||||||
| City: | OCEAN SPRINGS | ||||||||
| State: | MS | ||||||||
| PostalCode: | 395645721 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2288721951 | ||||||||
| FaxNumber: | 2288759998 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2007 | ||||||||
| LastUpdateDate: | 06/27/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | R753601 | MS | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | C00047 | 01 | MS | MEDICARE GROUP # | OTHER | 05078304 | 05 | MS | MEDICAID | 09014182 | 01 | MS | MEDICAID GROUP # | OTHER | 646000515 | 01 | BLUE CROSS OF MS | OTHER | 646000515 | 01 | TRICARE | OTHER | 500028696 | 01 | RAILROAD MEDICARE | OTHER |