Healthcare Provider Details

I. General information

NPI: 1023274750
Provider Name (Legal Business Name): TREASURE MARAE VAUGHN APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/01/2008
Last Update Date: 05/02/2023
Certification Date: 05/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

77 HAZZARD CREEK VLG UNIT C
RIDGELAND SC
29936-8266
US

IV. Provider business mailing address

29055 CLEMENS RD STE A
WESTLAKE OH
44145-1135
US

V. Phone/Fax

Practice location:
  • Phone: 843-645-7700
  • Fax:
Mailing address:
  • Phone: 216-450-1613
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number425109
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number130329
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number0029914
License Number StateOH
# 4
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number25822
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: