Provider Demographics
NPI:1235784950
Name:PAYNE, EBONY AKIMA
Entity Type:Individual
Prefix:
First Name:EBONY
Middle Name:AKIMA
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 1:1637 PARK ST
Mailing Address - Street 2:
Mailing Address - City:HARRISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17103-2337
Mailing Address - Country:US
Mailing Address - Phone:347-558-0094
Mailing Address - Fax:
Practice Address - Street 1:1637 PARK ST
Practice Address - Street 2:
Practice Address - City:HARRISBURG
Practice Address - State:PA
Practice Address - Zip Code:17103-2337
Practice Address - Country:US
Practice Address - Phone:718-695-2394
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-08
Last Update Date:2019-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA29117686172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172A00000XOther Service ProvidersDriverGroup - Single Specialty