Provider Demographics
NPI:1578668455
Name:PAYNE, PENNY RAE (PA)
Entity Type:Individual
Prefix:
First Name:PENNY
Middle Name:RAE
Last Name:PAYNE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:PENNY
Other - Middle Name:RAE
Other - Last Name:PAYNE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:1532 LONE OAK RD STE 320
Mailing Address - Street 2:
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42003-7942
Mailing Address - Country:US
Mailing Address - Phone:270-441-4300
Mailing Address - Fax:
Practice Address - Street 1:1532 LONE OAK RD STE 320
Practice Address - Street 2:
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42003-7942
Practice Address - Country:US
Practice Address - Phone:270-415-3830
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA769363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY95006011Medicaid
KYQ58450Medicare UPIN
KYP400022765Medicare PIN