Provider Demographics
NPI:1780162495
Name:VAUGHN, DIANE P
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:P
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:PO BOX 1000
Mailing Address - Street 2:
Mailing Address - City:BAYARD
Mailing Address - State:NM
Mailing Address - Zip Code:88023-1000
Mailing Address - Country:US
Mailing Address - Phone:575-537-4088
Mailing Address - Fax:575-537-3921
Practice Address - Street 1:900 A CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:BAYARD
Practice Address - State:NM
Practice Address - Zip Code:88023-8802
Practice Address - Country:US
Practice Address - Phone:575-537-4088
Practice Address - Fax:575-537-3921
Is Sole Proprietor?:No
Enumeration Date:2018-08-03
Last Update Date:2018-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMSLP-A6410235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM1477683316Medicaid