=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821648072
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NICOLE VAUGHN LPN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/18/2019
-----------------------------------------------------
Last Update Date | 09/18/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 140 N ASHLAND AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60607-1802
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-633-4972
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12608 S THROOP ST
-----------------------------------------------------
City | CALUMET PARK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60827-6115
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-983-9748
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 164W00000X
-----------------------------------------------------
Taxonomy Name | Licensed Practical Nurse
-----------------------------------------------------
License Number | 043105729
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------