Healthcare Provider Details

I. General information

NPI: 1356605000
Provider Name (Legal Business Name): CASSANDRA KAY PAYNE-DURBIN RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2012
Last Update Date: 06/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1520 4TH ST
LEWISPORT KY
42351-2529
US

IV. Provider business mailing address

PO BOX 304
LEWISPORT KY
42351-0304
US

V. Phone/Fax

Practice location:
  • Phone: 270-922-8098
  • Fax:
Mailing address:
  • Phone: 270-922-8098
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number1837
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: