Healthcare Provider Details

I. General information

NPI: 1295167351
Provider Name (Legal Business Name): COREY E PAYNE FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2013
Last Update Date: 06/30/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

389 FORGE RIDGE RD
HARROGATE TN
37752-7730
US

IV. Provider business mailing address

PO BOX 10988
KNOXVILLE TN
37939-0988
US

V. Phone/Fax

Practice location:
  • Phone: 423-869-5893
  • Fax: 423-869-3574
Mailing address:
  • Phone: 865-862-0998
  • Fax: 865-544-1861

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number17687
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number3009879
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: