Provider Demographics
NPI:1083297428
Name:VAUGHN, ANDREA NICOLE
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:NICOLE
Last Name:VAUGHN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22852 MILLARD AVE
Mailing Address - Street 2:
Mailing Address - City:RICHTON PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60471-2531
Mailing Address - Country:US
Mailing Address - Phone:708-362-1520
Mailing Address - Fax:
Practice Address - Street 1:22852 MILLARD AVE
Practice Address - Street 2:
Practice Address - City:RICHTON PARK
Practice Address - State:IL
Practice Address - Zip Code:60471-2531
Practice Address - Country:US
Practice Address - Phone:708-362-1520
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-04
Last Update Date:2021-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date: