Healthcare Provider Details

I. General information

NPI: 1053126987
Provider Name (Legal Business Name): PAYTON CONRAD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/10/2025
Last Update Date: 02/10/2025
Certification Date: 02/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1425 MALY BLVD
WAHOO NE
68066-4149
US

IV. Provider business mailing address

4411 WILLIAM ST
OMAHA NE
68105-1758
US

V. Phone/Fax

Practice location:
  • Phone: 630-397-1572
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WN0002X
TaxonomyNeonatal Intensive Care Registered Nurse
License Number91778
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: