Healthcare Provider Details

I. General information

NPI: 1952908816
Provider Name (Legal Business Name): KATHERINE A DOVER-PAYNE APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/05/2020
Last Update Date: 12/21/2023
Certification Date: 12/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

661 W 138TH ST
RIVERDALE IL
60827-1660
US

IV. Provider business mailing address

29373 NETWORK PL
CHICAGO IL
60673-1293
US

V. Phone/Fax

Practice location:
  • Phone: 219-515-4810
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209.021814
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: