Provider Demographics
NPI:1770259459
Name:VAUGHN, DERRICK LEE
Entity Type:Individual
Prefix:
First Name:DERRICK
Middle Name:LEE
Last Name:VAUGHN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:922 OGDEN AVE SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49506-3561
Mailing Address - Country:US
Mailing Address - Phone:313-974-9107
Mailing Address - Fax:
Practice Address - Street 1:209 DIVISION AVE S APT 107
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-4547
Practice Address - Country:US
Practice Address - Phone:313-974-9107
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-21
Last Update Date:2021-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374U00000XNursing Service Related ProvidersHome Health AideGroup - Single Specialty