Provider Demographics
NPI:1588713986
Name:VAUGHN, MARY JANE (PT)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:JANE
Last Name:VAUGHN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 W WACKER DRIVE
Mailing Address - Street 2:SUITE 1020
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60606-1216
Mailing Address - Country:US
Mailing Address - Phone:312-640-0329
Mailing Address - Fax:312-640-0407
Practice Address - Street 1:3160 8TH ST SW
Practice Address - Street 2:SUITE 1
Practice Address - City:ALTOONA
Practice Address - State:IA
Practice Address - Zip Code:50009-1023
Practice Address - Country:US
Practice Address - Phone:515-967-4580
Practice Address - Fax:515-967-4899
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2012-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070-001801225100000X
IA01243225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL070-001801OtherPT STATE LICENSE #
IL146636Medicare ID - Type Unspecified