Healthcare Provider Details

I. General information

NPI: 1356979769
Provider Name (Legal Business Name): CARLA M VAUGHN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: CARLA M MIGUEL

II. Dates (important events)

Enumeration Date: 03/31/2020
Last Update Date: 10/05/2026
Certification Date: 10/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

263 FARMINGTON AVE
FARMINGTON CT
06030-8036
US

IV. Provider business mailing address

263 FARMINGTON AVE
FARMINGTON CT
06030-8082
US

V. Phone/Fax

Practice location:
  • Phone: 860-679-4100
  • Fax: 860-679-1064
Mailing address:
  • Phone: 860-679-4100
  • Fax: 860-679-1064

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number79472
License Number StateMN
# 3
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number86705
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: