Healthcare Provider Details

I. General information

NPI: 1639695638
Provider Name (Legal Business Name): KIMBERLY MAY VAUGHN CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2017
Last Update Date: 01/28/2025
Certification Date: 01/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5450 FORT ST
TRENTON MI
48183-4601
US

IV. Provider business mailing address

21931 CANTERBURY AVE
GROSSE ILE MI
48138-1308
US

V. Phone/Fax

Practice location:
  • Phone: 734-642-2903
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number4704253471
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: