Provider Demographics
NPI:1760959209
Name:VAUGHN, LATONYA SHINESE (FNP)
Entity Type:Individual
Prefix:
First Name:LATONYA
Middle Name:SHINESE
Last Name:VAUGHN
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4149 W 79TH ST UNIT 2
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60652-2329
Mailing Address - Country:US
Mailing Address - Phone:773-407-0559
Mailing Address - Fax:
Practice Address - Street 1:4149 W 79TH ST UNIT 2
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60652-2329
Practice Address - Country:US
Practice Address - Phone:773-407-0559
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-01
Last Update Date:2023-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041.405551163W00000X
IL209018648363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILMV5172022OtherDEA