Provider Demographics
NPI:1457452518
Name:VAUGHN, PENNY JO (LPN)
Entity Type:Individual
Prefix:MRS
First Name:PENNY
Middle Name:JO
Last Name:VAUGHN
Suffix:
Gender:F
Credentials:LPN
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 155
Mailing Address - Street 2:REA CLINIC
Mailing Address - City:CHRISTOPHER
Mailing Address - State:IL
Mailing Address - Zip Code:62822
Mailing Address - Country:US
Mailing Address - Phone:618-724-2401
Mailing Address - Fax:618-724-2571
Practice Address - Street 1:1306 MAPLE STREET
Practice Address - Street 2:DOCTORS CLINIC
Practice Address - City:ELDORADO
Practice Address - State:IL
Practice Address - Zip Code:62930
Practice Address - Country:US
Practice Address - Phone:618-273-2360
Practice Address - Fax:618-273-4418
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse