Provider Demographics
NPI:1194925537
Name:VAUGHN, DIANE B (GNP)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:B
Last Name:VAUGHN
Suffix:
Gender:F
Credentials:GNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 555
Mailing Address - Street 2:
Mailing Address - City:BILOXI
Mailing Address - State:MS
Mailing Address - Zip Code:39533-0555
Mailing Address - Country:US
Mailing Address - Phone:228-865-3202
Mailing Address - Fax:228-865-3249
Practice Address - Street 1:1340 BROAD AVE
Practice Address - Street 2:SUITE 450
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39501-2404
Practice Address - Country:US
Practice Address - Phone:228-865-3202
Practice Address - Fax:228-865-3249
Is Sole Proprietor?:No
Enumeration Date:2007-07-24
Last Update Date:2010-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR621641363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS01128596Medicaid
MS01128596Medicaid
MS01128596Medicaid