Healthcare Provider Details

I. General information

NPI: 1609657527
Provider Name (Legal Business Name): PAYTON YORK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/06/2023
Last Update Date: 10/12/2023
Certification Date: 10/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 MEDICAL VILLAGE DR
EDGEWOOD KY
41017-5401
US

IV. Provider business mailing address

105 HUDSON AVE
LAKESIDE PARK KY
41017-2105
US

V. Phone/Fax

Practice location:
  • Phone: 859-578-5880
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number4007446
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4007446
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: