Provider Demographics
NPI:1639634702
Name:VAUGHN, LISA DIANE
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:DIANE
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 1:1209 MARIETTA DR
Mailing Address - Street 2:
Mailing Address - City:FAIRBORN
Mailing Address - State:OH
Mailing Address - Zip Code:45324-5726
Mailing Address - Country:US
Mailing Address - Phone:937-657-2204
Mailing Address - Fax:
Practice Address - Street 1:1209 MARIETTA DR
Practice Address - Street 2:
Practice Address - City:FAIRBORN
Practice Address - State:OH
Practice Address - Zip Code:45324-5726
Practice Address - Country:US
Practice Address - Phone:937-657-2204
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-04
Last Update Date:2019-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH006264224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant