Provider Demographics
NPI:1851575138
Name:PAYNE, NICOLE LYNN (CFNP)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:LYNN
Last Name:PAYNE
Suffix:
Gender:F
Credentials:CFNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4631 STONE PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:OLIVE BRANCH
Mailing Address - State:MS
Mailing Address - Zip Code:38654-6983
Mailing Address - Country:US
Mailing Address - Phone:662-873-3467
Mailing Address - Fax:
Practice Address - Street 1:3451 GOODMAN RD E
Practice Address - Street 2:SUITE 115
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38672-9303
Practice Address - Country:US
Practice Address - Phone:662-890-5555
Practice Address - Fax:662-890-8899
Is Sole Proprietor?:No
Enumeration Date:2007-12-23
Last Update Date:2012-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR870070363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS3025I04128Medicare PIN