Provider Demographics
NPI:1922368364
Name:VAUGHAN, CANDICE ELIZABETH-SWEETY
Entity Type:Individual
Prefix:MISS
First Name:CANDICE
Middle Name:ELIZABETH-SWEETY
Last Name:VAUGHAN
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 1:1455 N MAIN ST
Mailing Address - Street 2:APT. 201B
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89101-1092
Mailing Address - Country:US
Mailing Address - Phone:702-375-4204
Mailing Address - Fax:
Practice Address - Street 1:1455 N MAIN ST
Practice Address - Street 2:APT. 201B
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89101-1092
Practice Address - Country:US
Practice Address - Phone:702-375-4204
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-18
Last Update Date:2012-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV45-3558217Medicaid