Provider Demographics
NPI:1811210628
Name:VAUGHN, LAURA ELISE
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:ELISE
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 1:1898 30TH AVE S APT 206
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201-8909
Mailing Address - Country:US
Mailing Address - Phone:218-779-4237
Mailing Address - Fax:
Practice Address - Street 1:2400 47TH AVE S
Practice Address - Street 2:
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201-3405
Practice Address - Country:US
Practice Address - Phone:701-746-2230
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-08
Last Update Date:2010-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1109235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND55610Medicaid