Provider Demographics
NPI:1124662366
Name:COLEMAN-VAUGHN, TREAVA
Entity type:Individual
Prefix:
First Name:TREAVA
Middle Name:
Last Name:COLEMAN-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 1:6301 CAMP ROBINSON RD APT L169
Mailing Address - Street 2:
Mailing Address - City:NORTH LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72118-2888
Mailing Address - Country:US
Mailing Address - Phone:501-240-7961
Mailing Address - Fax:
Practice Address - Street 1:6301 CAMP ROBINSON RD APT L169
Practice Address - Street 2:
Practice Address - City:NORTH LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72118-2888
Practice Address - Country:US
Practice Address - Phone:501-240-7961
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-31
Last Update Date:2019-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR050212020808E376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide