Provider Demographics
NPI:1417444969
Name:VAUGHN, EBONI (FNP)
Entity Type:Individual
Prefix:
First Name:EBONI
Middle Name:
Last Name:VAUGHN
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:EBONI
Other - Middle Name:
Other - Last Name:SIMMONS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5309 IMPERIAL DR
Mailing Address - Street 2:
Mailing Address - City:RICHTON PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60471-1557
Mailing Address - Country:US
Mailing Address - Phone:708-297-7325
Mailing Address - Fax:
Practice Address - Street 1:63 W 87TH ST
Practice Address - Street 2:
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60565
Practice Address - Country:US
Practice Address - Phone:630-778-7645
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-20
Last Update Date:2018-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209017491363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty