Provider Demographics
NPI:1760048334
Name:PAYNE, VICTORIA SUE (MSN, RN, FNP-BC)
Entity Type:Individual
Prefix:MS
First Name:VICTORIA
Middle Name:SUE
Last Name:PAYNE
Suffix:
Gender:F
Credentials:MSN, RN, FNP-BC
Other - Prefix:
Other - First Name:VICTORIA
Other - Middle Name:S
Other - Last Name:GUTHRIE, OLSEN, GOODMAN, CADENA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2214 N UNIVERSITY ST
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61604-3221
Mailing Address - Country:US
Mailing Address - Phone:309-495-8644
Mailing Address - Fax:309-681-8443
Practice Address - Street 1:1800 N KNOXVILLE AVE STE A
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61603-3005
Practice Address - Country:US
Practice Address - Phone:309-680-7669
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-19
Last Update Date:2024-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.019427363LF0000X
IL041.396677163WP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WP0200XNursing Service ProvidersRegistered NursePediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209.019427OtherIL STATE NURSE PRACTITIONER LICENSE