1760048334 NPI number — MS. VICTORIA SUE PAYNE MSN, RN, FNP-BC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760048334 NPI number — MS. VICTORIA SUE PAYNE MSN, RN, FNP-BC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PAYNE
Provider First Name:
VICTORIA
Provider Middle Name:
SUE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
MSN, RN, FNP-BC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GUTHRIE, OLSEN, GOODMAN, CADENA
Provider Other First Name:
VICTORIA
Provider Other Middle Name:
S
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1760048334
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/04/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2214 N UNIVERSITY ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PEORIA
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61604-3221
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
309-495-8644
Provider Business Mailing Address Fax Number:
309-681-8443

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1800 N KNOXVILLE AVE STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PEORIA
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61603-3005
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
309-680-7669
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/19/2019

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  209.019427 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 163WP0200X , with the licence number: 041.396677 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 209.019427 . This is a "IL STATE NURSE PRACTITIONER LICENSE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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