Basic Information
| Provider Information | |||||||||
| NPI: | 1093175630 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VAUGHT | ||||||||
| FirstName: | ELIZABETH | ||||||||
| MiddleName: | BRIANNE | ||||||||
| NamePrefix: | MISS | ||||||||
| NameSuffix: | |||||||||
| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 781076 | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482781076 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3175284800 | ||||||||
| FaxNumber: | 3178651479 | ||||||||
| Practice Location | |||||||||
| Address1: | 2150 GETTLER ST | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | DYER | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463112380 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2198650893 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/24/2016 | ||||||||
| LastUpdateDate: | 03/15/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WG0000X | 041354593 | IL | N | Nursing Service Providers | Registered Nurse | General Practice | 163WG0000X | 209012854 | IL | N | Nursing Service Providers | Registered Nurse | General Practice | 163WG0000X | 28172376A | IN | N | Nursing Service Providers | Registered Nurse | General Practice | 363L00000X | 71006196A | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 201401700 | 05 | IN | MEDICAID |