Provider Demographics
NPI:1528651825
Name:VAUGHN, ANITA L II
Entity type:Individual
Prefix:
First Name:ANITA
Middle Name:L
Last Name:VAUGHN
Suffix:II
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 1:1451 ROBERTS RD
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38106-6938
Mailing Address - Country:US
Mailing Address - Phone:901-406-3759
Mailing Address - Fax:
Practice Address - Street 1:1451 ROBERTS RD
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38106-6938
Practice Address - Country:US
Practice Address - Phone:901-406-3759
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-17
Last Update Date:2021-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN347E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347E00000XTransportation ServicesTransportation Broker
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN172A00000Medicaid