Basic Information
| Provider Information | |||||||||
| NPI: | 1710180393 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VAUGHT | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 23229 | ||||||||
| Address2: | |||||||||
| City: | OWENSBORO | ||||||||
| State: | KY | ||||||||
| PostalCode: | 423043229 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2706868500 | ||||||||
| FaxNumber: | 2706855467 | ||||||||
| Practice Location | |||||||||
| Address1: | 1325 TRIPLETT STREET | ||||||||
| Address2: | |||||||||
| City: | OWENSBORO | ||||||||
| State: | KY | ||||||||
| PostalCode: | 423033163 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2706868500 | ||||||||
| FaxNumber: | 2706855467 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2007 | ||||||||
| LastUpdateDate: | 05/14/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP2300X | 3005254 | KY | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Primary Care | 363L00000X | 3005254 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 7100012620 | 05 | KY | MEDICAID | 3005254P | 01 | KY | KENTUCKY LICENSURE BOARD | OTHER |