Provider Demographics
NPI:1689371049
Name:EMPOWERED PEDIATRICS LLC
Entity Type:Organization
Organization Name:EMPOWERED PEDIATRICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRIC NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:JERRICA
Authorized Official - Middle Name:
Authorized Official - Last Name:VAUGHAN
Authorized Official - Suffix:
Authorized Official - Credentials:CPNP
Authorized Official - Phone:262-307-1319
Mailing Address - Street 1:W229N1433 WESTWOOD DR STE 104
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53186-1172
Mailing Address - Country:US
Mailing Address - Phone:262-307-1319
Mailing Address - Fax:855-857-9099
Practice Address - Street 1:W229N1433 WESTWOOD DR STE 104
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53186-1172
Practice Address - Country:US
Practice Address - Phone:262-307-1319
Practice Address - Fax:855-857-9099
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-02-15
Last Update Date:2023-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health