Healthcare Provider Details

I. General information

NPI: 1164879904
Provider Name (Legal Business Name): ILLYA PAYNE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/23/2016
Last Update Date: 05/23/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6095 MARSHALEE DR
ELKRIDGE MD
21075-6053
US

IV. Provider business mailing address

6095 MARSHALEE DR
ELKRIDGE MD
21075-6053
US

V. Phone/Fax

Practice location:
  • Phone: 855-247-8474
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2015027443
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number20164
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: