Healthcare Provider Details

I. General information

NPI: 1164646824
Provider Name (Legal Business Name): MRS. JUDI ANN VAUGHAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/12/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

316 MARION PIKE
COAL GROVE OH
45638-2957
US

IV. Provider business mailing address

216 BELFONTE ST
RUSSELL KY
41169-1317
US

V. Phone/Fax

Practice location:
  • Phone: 740-532-6143
  • Fax:
Mailing address:
  • Phone: 606-836-0683
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code372500000X
TaxonomyChore Provider
License Number2421025
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: