Provider Demographics
NPI:1154908606
Name:VAUGHAN, LUCILLE TERESE (FPS)
Entity type:Individual
Prefix:
First Name:LUCILLE
Middle Name:TERESE
Last Name:VAUGHAN
Suffix:
Gender:F
Credentials:FPS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:208 ROANOKE AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERHEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11901-2706
Mailing Address - Country:US
Mailing Address - Phone:631-772-3287
Mailing Address - Fax:631-284-2541
Practice Address - Street 1:208 ROANOKE AVE
Practice Address - Street 2:
Practice Address - City:RIVERHEAD
Practice Address - State:NY
Practice Address - Zip Code:11901-2706
Practice Address - Country:US
Practice Address - Phone:631-772-3287
Practice Address - Fax:631-284-2541
Is Sole Proprietor?:No
Enumeration Date:2021-03-29
Last Update Date:2021-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker