Basic Information
| Provider Information | |||||||||
| NPI: | 1558805606 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VAUGHAN | ||||||||
| FirstName: | PATIENCE | ||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2073 GARDEN ST | ||||||||
| Address2: | |||||||||
| City: | TITUSVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327963243 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3218883020 | ||||||||
| FaxNumber: | 6612634584 | ||||||||
| Practice Location | |||||||||
| Address1: | 7075 N HIGHWAY 1 | ||||||||
| Address2: | |||||||||
| City: | COCOA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329275216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3218883020 | ||||||||
| FaxNumber: | 6612634584 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/08/2016 | ||||||||
| LastUpdateDate: | 11/04/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/04/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | RBT-16-21415 | FL | Y |
ID Information
| ID | Type | State | Issuer | Description | 16-21415 | 01 | FL | RBT | OTHER |