1871966796 NPI number — MS. CHRISTINE ANN VAUGHAN FNP

Table of content: MS. CHRISTINE ANN VAUGHAN FNP (NPI 1871966796)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871966796 NPI number — MS. CHRISTINE ANN VAUGHAN FNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VAUGHAN
Provider First Name:
CHRISTINE
Provider Middle Name:
ANN
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
FNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1871966796
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/25/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 505500
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAINT LOUIS
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63150-5500
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
636-349-5437
Provider Business Mailing Address Fax Number:
636-349-6663

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
714 GRAVOIS RD
Provider Second Line Business Practice Location Address:
STE 200
Provider Business Practice Location Address City Name:
FENTON
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63026-7766
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
636-349-5437
Provider Business Practice Location Address Fax Number:
636-349-6663
Provider Enumeration Date:
11/02/2015

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  2020029683 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 420090531 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".




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