Provider Demographics
NPI:1306830468
Name:PAYNE, SHELLEY (APRN)
Entity Type:Individual
Prefix:MRS
First Name:SHELLEY
Middle Name:
Last Name:PAYNE
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4411 HIGHWAY 5 N
Mailing Address - Street 2:
Mailing Address - City:BRYANT
Mailing Address - State:AR
Mailing Address - Zip Code:72022-7005
Mailing Address - Country:US
Mailing Address - Phone:501-847-0289
Mailing Address - Fax:501-847-8748
Practice Address - Street 1:4411 HIGHWAY 5 N
Practice Address - Street 2:
Practice Address - City:BRYANT
Practice Address - State:AR
Practice Address - Zip Code:72022-7005
Practice Address - Country:US
Practice Address - Phone:501-847-0289
Practice Address - Fax:501-847-8748
Is Sole Proprietor?:No
Enumeration Date:2005-09-06
Last Update Date:2017-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA01505363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR162274758Medicaid
5Y394OtherBCBS
ARA01505OtherCHAMPUS
5Y394OtherBCBS
AR5Y394Medicare ID - Type Unspecified