Healthcare Provider Details

I. General information

NPI: 1780320028
Provider Name (Legal Business Name): KORIN ELISE VAUGHN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2022
Last Update Date: 05/08/2023
Certification Date: 05/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1740 W TAYLOR ST
CHICAGO IL
60612-7232
US

IV. Provider business mailing address

148 MANSFIELD AVE APT 18
SHELBY OH
44875-8624
US

V. Phone/Fax

Practice location:
  • Phone: 312-996-7298
  • Fax: 312-413-0289
Mailing address:
  • Phone: 419-566-8605
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085009238
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: