Basic Information
| Provider Information | |||||||||
| NPI: | 1649459108 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VAUGHAN | ||||||||
| FirstName: | KRISTA | ||||||||
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| Credential: | OT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3320 N CLINTON ST | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468051918 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2604832100 | ||||||||
| FaxNumber: | 2604845059 | ||||||||
| Practice Location | |||||||||
| Address1: | 3320 N CLINTON ST | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468051918 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2604832100 | ||||||||
| FaxNumber: | 2604845059 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/31/2007 | ||||||||
| LastUpdateDate: | 11/13/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 31004498A | IN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
ID Information
| ID | Type | State | Issuer | Description | 200868170 | 05 | IN | MEDICAID | 000000530791 | 01 | IN | ANTHEM | OTHER |