Provider Demographics
NPI:1811026131
Name:VAUGHN, KELLYE S (LMP)
Entity type:Individual
Prefix:MS
First Name:KELLYE
Middle Name:S
Last Name:VAUGHN
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 52
Mailing Address - Street 2:
Mailing Address - City:MUKILTEO
Mailing Address - State:WA
Mailing Address - Zip Code:98275-0052
Mailing Address - Country:US
Mailing Address - Phone:425-418-4207
Mailing Address - Fax:425-265-9484
Practice Address - Street 1:4430 76TH ST SW
Practice Address - Street 2:
Practice Address - City:MUKILTEO
Practice Address - State:WA
Practice Address - Zip Code:98275-2745
Practice Address - Country:US
Practice Address - Phone:425-418-4207
Practice Address - Fax:425-265-9484
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00011883225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist