Healthcare Provider Details

I. General information

NPI: 1093175630
Provider Name (Legal Business Name): ELIZABETH BRIANNE VAUGHT NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/24/2016
Last Update Date: 04/03/2024
Certification Date: 04/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2150 GETTLER ST STE 400
DYER IN
46311-2385
US

IV. Provider business mailing address

PO BOX 781076
DETROIT MI
48278-1076
US

V. Phone/Fax

Practice location:
  • Phone: 219-865-0893
  • Fax: 219-865-3599
Mailing address:
  • Phone: 317-528-4800
  • Fax: 317-865-1479

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number041354593
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number209012854
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number28172376A
License Number StateIN
# 4
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number71006196A
License Number StateIN
# 5
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number71006196A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: