1700831138 NPI number — MRS. ELIZABETH DIANE PAYNE APRN

Table of content: MRS. ELIZABETH DIANE PAYNE APRN (NPI 1700831138)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700831138 NPI number — MRS. ELIZABETH DIANE PAYNE APRN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PAYNE
Provider First Name:
ELIZABETH
Provider Middle Name:
DIANE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
APRN
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1700831138
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/18/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10821 PLANTSIDE DRIVE
Provider Second Line Business Mailing Address:
SUITE 104
Provider Business Mailing Address City Name:
LOUISVILLE
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40299
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
502-412-2995
Provider Business Mailing Address Fax Number:
502-412-8025

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10821 PLANTSIDE DRIVE
Provider Second Line Business Practice Location Address:
SUITE 104
Provider Business Practice Location Address City Name:
LOUISVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40299
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-412-2995
Provider Business Practice Location Address Fax Number:
502-412-8025
Provider Enumeration Date:
05/24/2006

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: 363LA2200X , with the licence number:  3002826 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 500028827 . This is a "PASSPORT PROV NUMBER" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 7765491 . This is a "AETNA PIN" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 78028263 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 201016000 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2444184000 . This is a "PASSPORT ADVANTAGE" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 000000240200 . This is a "ANTHEM PROV NUMBER" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".




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