Basic Information
| Provider Information | |||||||||
| NPI: | 1700929734 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EVERETT | ||||||||
| FirstName: | VAUGHNNA | ||||||||
| MiddleName: | LUCINDA | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | FNP-BC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | TORBETT | ||||||||
| OtherFirstName: | VAUGHNNA | ||||||||
| OtherMiddleName: | LUCINDA | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | FNP-BC | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 497 WINN WAY | ||||||||
| Address2: | SUITE A210 | ||||||||
| City: | DECATUR | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300301754 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4046457150 | ||||||||
| FaxNumber: | 4046457107 | ||||||||
| Practice Location | |||||||||
| Address1: | 497 WINN WAY | ||||||||
| Address2: | SUITE A210 | ||||||||
| City: | DECATUR | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300301754 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4046457150 | ||||||||
| FaxNumber: | 4046457107 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/15/2007 | ||||||||
| LastUpdateDate: | 09/17/2015 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | RN118166 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 460374361A | 05 | GA | MEDICAID | 10036227 | 01 | GA | AMERIGROUP | OTHER | 900295258A | 05 | GA | MEDICAID |