Healthcare Provider Details

I. General information

NPI: 1821952854
Provider Name (Legal Business Name): THOMAS KELLY PAYNTER RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/15/2025
Last Update Date: 12/15/2025
Certification Date: 12/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1320 MAPLEWOOD AVE
RONCEVERTE WV
24970-8016
US

IV. Provider business mailing address

312 HEATHERTON DR
COVINGTON VA
24426-6336
US

V. Phone/Fax

Practice location:
  • Phone: 304-647-6080
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License Number100220
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: