Provider Demographics
NPI:1730680745
Name:PAYNE, KIONNA LASHAUN (LPN)
Entity Type:Individual
Prefix:
First Name:KIONNA
Middle Name:LASHAUN
Last Name:PAYNE
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 FAIR ST SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49507-1749
Mailing Address - Country:US
Mailing Address - Phone:773-946-6153
Mailing Address - Fax:
Practice Address - Street 1:125 FAIR ST SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49507-1749
Practice Address - Country:US
Practice Address - Phone:773-946-6153
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-24
Last Update Date:2018-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703105261164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse