Healthcare Provider Details

I. General information

NPI: 1760048334
Provider Name (Legal Business Name): VICTORIA SUE PAYNE MSN, RN, FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: VICTORIA S GUTHRIE, OLSEN, GOODMAN, CADENA

II. Dates (important events)

Enumeration Date: 05/19/2019
Last Update Date: 03/04/2024
Certification Date: 03/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 N KNOXVILLE AVE STE A
PEORIA IL
61603-3005
US

IV. Provider business mailing address

2214 N UNIVERSITY ST
PEORIA IL
61604-3221
US

V. Phone/Fax

Practice location:
  • Phone: 309-680-7669
  • Fax:
Mailing address:
  • Phone: 309-495-8644
  • Fax: 309-681-8443

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209.019427
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License Number041.396677
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: