Provider Demographics
NPI:1578252276
Name:PAYNE, PORTIA
Entity Type:Individual
Prefix:MS
First Name:PORTIA
Middle Name:
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 1:7615 CLARINGTON CV
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671-5647
Mailing Address - Country:US
Mailing Address - Phone:662-536-2500
Mailing Address - Fax:
Practice Address - Street 1:7615 CLARINGTON CV
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-5647
Practice Address - Country:US
Practice Address - Phone:662-536-2500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-08
Last Update Date:2024-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN33553363LF0000X
MS906266363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily