Provider Demographics
NPI:1063609287
Name:VAUGHAN, POLLY S (CRNP)
Entity type:Individual
Prefix:
First Name:POLLY
Middle Name:S
Last Name:VAUGHAN
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6100 GURNEYVILLE RD
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:OH
Mailing Address - Zip Code:45177-6508
Mailing Address - Country:US
Mailing Address - Phone:937-313-4400
Mailing Address - Fax:937-488-1414
Practice Address - Street 1:630 EATON AVE # 2W
Practice Address - Street 2:
Practice Address - City:HAMILTON
Practice Address - State:OH
Practice Address - Zip Code:45013
Practice Address - Country:US
Practice Address - Phone:513-867-2433
Practice Address - Fax:513-867-2499
Is Sole Proprietor?:No
Enumeration Date:2007-10-02
Last Update Date:2024-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHNP-09551363LP0200X
OHAPRN.CNP.09551363LF0000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily