Provider Demographics
NPI:1760596928
Name:VAUGHN-WHITLEY, KELLY (MD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:VAUGHN-WHITLEY
Suffix:
Gender:F
Credentials:MD
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 706
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57709-0706
Mailing Address - Country:US
Mailing Address - Phone:605-341-1300
Mailing Address - Fax:605-341-8785
Practice Address - Street 1:13975 NECK YOKE RD
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57702-7314
Practice Address - Country:US
Practice Address - Phone:605-341-1300
Practice Address - Fax:605-341-8785
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2021-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE17679207RC0000X
SD3531207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
SDS4544Medicare PIN