Healthcare Provider Details

I. General information

NPI: 1265779110
Provider Name (Legal Business Name): KRISTINE VAUGHN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/12/2013
Last Update Date: 01/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3100 LITTLE RD
TRINITY FL
34655-1864
US

IV. Provider business mailing address

3100 LITTLE RD
TRINITY FL
34655-1864
US

V. Phone/Fax

Practice location:
  • Phone: 727-375-1609
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPS32643
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: