1780162495 NPI number — DIANE P. VAUGHN

Table of content: DIANE P. VAUGHN (NPI 1780162495)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780162495 NPI number — DIANE P. VAUGHN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VAUGHN
Provider First Name:
DIANE
Provider Middle Name:
P.
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1780162495
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/03/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1000
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BAYARD
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
88023-1000
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
575-537-4088
Provider Business Mailing Address Fax Number:
575-537-3921

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
900 A CENTRAL AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BAYARD
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
88023-8802
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
575-537-4088
Provider Business Practice Location Address Fax Number:
575-537-3921
Provider Enumeration Date:
08/03/2018

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 235Z00000X , with the licence number:  SLP-A6410 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1477683316 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".




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