MEDICARE: TIFFANY JOI VAUGHN NP-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	343637	NY

General Provider Information

NPI Number	:	1750866810
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TIFFANY JOI VAUGHN NP-C

Provider Business Mailing Address
First Line	:	80204A N LEWIS ST
Second Line	:
City	:	FORT DRUM
State	:	NY
Zip	:	13603-4091
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	19316 US ROUTE 11
Second Line	:	BUILDING IV, SUITE C
City	:	WATERTOWN
State	:	NY
Zip	:	13601
Country	:	US
Telephone Number	:	315-681-4192
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/25/2018
Last Update Date	:	09/25/2018

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