Healthcare Provider Details

I. General information

NPI: 1063771962
Provider Name (Legal Business Name): CARLA S PAYNE RN, MSN, FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2012
Last Update Date: 04/25/2025
Certification Date: 04/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5999 W MEMORY LN STE 1
GREENFIELD IN
46140-7294
US

IV. Provider business mailing address

6572 W CHARLESTON WAY
MCCORDSVILLE IN
46055-9677
US

V. Phone/Fax

Practice location:
  • Phone: 317-779-1204
  • Fax: 317-940-5759
Mailing address:
  • Phone: 317-407-6808
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number28160871A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number71004088A
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number71004088A
License Number StateIN
# 4
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number71004088A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: