Healthcare Provider Details

I. General information

NPI: 1801790282
Provider Name (Legal Business Name): CRYSTAL VAUGHN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/07/2026
Last Update Date: 10/07/2026
Certification Date: 10/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

716 E MAIN PL
JENKS OK
74037
US

IV. Provider business mailing address

14134 E 19TH PL
TULSA OK
74108-5508
US

V. Phone/Fax

Practice location:
  • Phone: 918-209-5190
  • Fax:
Mailing address:
  • Phone: 720-731-7080
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: