MEDICARE: WALEA TETEE KOFA-PAYNE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	RN613264	PA
2	163WH0200X	Home Health Registered Nurse	RN613264	PA

General Provider Information

NPI Number	:	1386502763
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WALEA TETEE KOFA-PAYNE

Provider Business Mailing Address
First Line	:	7748 JACKSON ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19136-3252
Country	:	US
Telephone Number	:	267-235-5270
Fax Number	:

Provider Business Practice Location Address
First Line	:	7748 JACKSON ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19136-3252
Country	:	US
Telephone Number	:	267-235-5270
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/13/2026
Last Update Date	:	01/13/2026

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