Provider Demographics
NPI:1174070684
Name:DEVAUGHN, MALORIE (ACNPC-AG)
Entity type:Individual
Prefix:
First Name:MALORIE
Middle Name:
Last Name:DEVAUGHN
Suffix:
Gender:F
Credentials:ACNPC-AG
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 2040
Mailing Address - Street 2:
Mailing Address - City:CORINTH
Mailing Address - State:MS
Mailing Address - Zip Code:38835-2040
Mailing Address - Country:US
Mailing Address - Phone:662-293-1000
Mailing Address - Fax:662-293-4323
Practice Address - Street 1:611 ALCORN DR
Practice Address - Street 2:
Practice Address - City:CORINTH
Practice Address - State:MS
Practice Address - Zip Code:38834-9321
Practice Address - Country:US
Practice Address - Phone:662-293-1000
Practice Address - Fax:662-293-4323
Is Sole Proprietor?:No
Enumeration Date:2016-09-01
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS901724363LA2100X, 363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology