Healthcare Provider Details

I. General information

NPI: 1942244124
Provider Name (Legal Business Name): DOUGLAS HOWARD PAYNE CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/16/2006
Last Update Date: 01/17/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1350 HICKORY ST
MELBOURNE FL
32901-3224
US

IV. Provider business mailing address

407 HIGHWAY A1A APT 452
SATELLITE BEACH FL
32937-2329
US

V. Phone/Fax

Practice location:
  • Phone: 321-434-7000
  • Fax:
Mailing address:
  • Phone: 910-792-0199
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number168953
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number168953
License Number StateNC
# 3
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberARNP9283899
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: