Provider Demographics
NPI:1497000111
Name:PAYNE, DOMINIQUE M (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:M
Last Name:PAYNE
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:DOMINIQUE
Other - Middle Name:M
Other - Last Name:VANNELLI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CCC-SLP
Mailing Address - Street 1:3024 BRENT GRAY TRCE
Mailing Address - Street 2:
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42303-2717
Mailing Address - Country:US
Mailing Address - Phone:401-787-5235
Mailing Address - Fax:
Practice Address - Street 1:911 COLLEGE ST STE 205
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42101-2183
Practice Address - Country:US
Practice Address - Phone:270-551-2032
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-18
Last Update Date:2023-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN5441235Z00000X
KY266782235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist