Healthcare Provider Details

I. General information

NPI: 1437758489
Provider Name (Legal Business Name): JILLIAN VAUGHAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/21/2020
Last Update Date: 05/04/2021
Certification Date: 05/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 W MYRTLE ST
BOISE ID
83702-7656
US

IV. Provider business mailing address

6293 N PORTSMOUTH AVE
BOISE ID
83714-6111
US

V. Phone/Fax

Practice location:
  • Phone: 208-342-8200
  • Fax:
Mailing address:
  • Phone: 541-961-4735
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WN0800X
TaxonomyNeuroscience Registered Nurse
License Number53890
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number53890
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: