Provider Demographics
NPI:1346838067
Name:VAUGHN, BERONDA (LPN)
Entity type:Individual
Prefix:
First Name:BERONDA
Middle Name:
Last Name:VAUGHN
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 OHIO RIVER DR
Mailing Address - Street 2:
Mailing Address - City:ADRIAN
Mailing Address - State:MI
Mailing Address - Zip Code:49221-3762
Mailing Address - Country:US
Mailing Address - Phone:517-306-7059
Mailing Address - Fax:
Practice Address - Street 1:100 POWELL DR STE 1
Practice Address - Street 2:
Practice Address - City:DUNDEE
Practice Address - State:MI
Practice Address - Zip Code:48131-8645
Practice Address - Country:US
Practice Address - Phone:517-299-1481
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-07
Last Update Date:2021-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN138136164W00000X
MI4703105359164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse