Healthcare Provider Details

I. General information

NPI: 1063609287
Provider Name (Legal Business Name): POLLY S VAUGHAN CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2007
Last Update Date: 01/25/2024
Certification Date: 01/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

630 EATON AVE # 2W
HAMILTON OH
45013
US

IV. Provider business mailing address

6100 GURNEYVILLE RD
WILMINGTON OH
45177-6508
US

V. Phone/Fax

Practice location:
  • Phone: 513-867-2433
  • Fax: 513-867-2499
Mailing address:
  • Phone: 937-313-4400
  • Fax: 937-488-1414

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberNP-09551
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN.CNP.09551
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAPRN.CNP.09551
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: