Basic Information
| Provider Information | |||||||||
| NPI: | 1760989115 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VAUGHN | ||||||||
| FirstName: | KERRY | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | CRNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12311 PERRY HWY | ||||||||
| Address2: | |||||||||
| City: | WEXFORD | ||||||||
| State: | PA | ||||||||
| PostalCode: | 150908344 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8783324159 | ||||||||
| FaxNumber: | 8783324479 | ||||||||
| Practice Location | |||||||||
| Address1: | 12311 PERRY HWY FL 1 | ||||||||
| Address2: | |||||||||
| City: | WEXFORD | ||||||||
| State: | PA | ||||||||
| PostalCode: | 15090 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8783324174 | ||||||||
| FaxNumber: | 8783324479 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/11/2018 | ||||||||
| LastUpdateDate: | 10/02/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/02/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | SP018735 | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.