Provider Demographics
NPI:1245768662
Name:VAUGHAN, JERRICA BRIANNE (CPNP-PC)
Entity Type:Individual
Prefix:MRS
First Name:JERRICA
Middle Name:BRIANNE
Last Name:VAUGHAN
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Gender:F
Credentials:CPNP-PC
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Mailing Address - Street 1:9000 W WISCONSIN AVE # MS 958
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-4874
Mailing Address - Country:US
Mailing Address - Phone:414-266-7615
Mailing Address - Fax:414-266-6238
Practice Address - Street 1:4855 S MOORLAND RD STE 250
Practice Address - Street 2:
Practice Address - City:NEW BERLIN
Practice Address - State:WI
Practice Address - Zip Code:53151-7494
Practice Address - Country:US
Practice Address - Phone:262-789-6020
Practice Address - Fax:262-789-6025
Is Sole Proprietor?:No
Enumeration Date:2017-05-30
Last Update Date:2023-07-10
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
WI202274632080P0006X
WI226174163W00000X
WI7420363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0006XAllopathic & Osteopathic PhysiciansPediatricsDevelopmental - Behavioral Pediatrics
No163W00000XNursing Service ProvidersRegistered Nurse
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1245768662Medicaid