Provider Demographics
NPI:1013388784
Name:PAYNE, ALEXA T
Entity Type:Individual
Prefix:
First Name:ALEXA
Middle Name:T
Last Name:PAYNE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2605 KENTUCKY AVE
Mailing Address - Street 2:SUITE 306
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42003-3800
Mailing Address - Country:US
Mailing Address - Phone:270-415-7653
Mailing Address - Fax:270-575-8359
Practice Address - Street 1:2605 KENTUCKY AVE
Practice Address - Street 2:SUITE 601
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42003-3800
Practice Address - Country:US
Practice Address - Phone:270-408-4368
Practice Address - Fax:270-408-3272
Is Sole Proprietor?:No
Enumeration Date:2015-10-07
Last Update Date:2020-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3009642363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100385080Medicaid
KY7100385080Medicaid