Provider Demographics
NPI:1326038803
Name:PHAYNE, NAOMI (DPM)
Entity Type:Individual
Prefix:
First Name:NAOMI
Middle Name:
Last Name:PHAYNE
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:650 JOEL DRIVE
Mailing Address - Street 2:PODIATRY CLINIC
Mailing Address - City:FORT CAMPBELL
Mailing Address - State:KY
Mailing Address - Zip Code:42223
Mailing Address - Country:US
Mailing Address - Phone:702-798-8638
Mailing Address - Fax:
Practice Address - Street 1:650 JOEL DRIVE
Practice Address - Street 2:PODIATRY CLINIC
Practice Address - City:FORT CAMPBELL
Practice Address - State:KY
Practice Address - Zip Code:42223
Practice Address - Country:US
Practice Address - Phone:270-798-8638
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-25
Last Update Date:2023-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD01395213E00000X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist