Provider Demographics
NPI:1023195286
Name:PAYNE, MARY KATHRYN (NP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:KATHRYN
Last Name:PAYNE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3621 S STATE ST
Mailing Address - Street 2:700 KMS PLACE
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48108
Mailing Address - Country:US
Mailing Address - Phone:734-936-2047
Mailing Address - Fax:
Practice Address - Street 1:2850 S INDUSTRIAL HWY
Practice Address - Street 2:#75
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48104-6796
Practice Address - Country:US
Practice Address - Phone:734-677-1515
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2017-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704126433363LA2200X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4704507Medicaid
MIP22077Medicare UPIN
MI4704507Medicaid