Provider Demographics
NPI:1326429887
Name:VAUGHN, OCTAVIA SJHANETTE
Entity Type:Individual
Prefix:
First Name:OCTAVIA
Middle Name:SJHANETTE
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 1:2150 W 117TH ST # 1102
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44111-1641
Mailing Address - Country:US
Mailing Address - Phone:216-309-7999
Mailing Address - Fax:
Practice Address - Street 1:2150 W 117TH ST # 1102
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44111-1641
Practice Address - Country:US
Practice Address - Phone:216-309-7999
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-10
Last Update Date:2024-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLPN.188397164W00000X
OH374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse