Healthcare Provider Details

I. General information

NPI: 1598937211
Provider Name (Legal Business Name): ABRA PAYNE LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/02/2008
Last Update Date: 04/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

705 OLD 63 S
COLUMBIA MO
65201-6065
US

IV. Provider business mailing address

705 OLD 63 S
COLUMBIA MO
65201-6065
US

V. Phone/Fax

Practice location:
  • Phone: 573-823-8986
  • Fax: 573-442-3538
Mailing address:
  • Phone: 573-823-8986
  • Fax: 573-442-3538

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number2000170576
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code172A00000X
TaxonomyDriver
License Number2000170576
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code374700000X
TaxonomyTechnician
License Number2000170576
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: