Provider Demographics
NPI:1851758163
Name:PAYNE, ERICA QUITERRA
Entity Type:Individual
Prefix:
First Name:ERICA
Middle Name:QUITERRA
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 1:290 COUNTRY CLUB DR
Mailing Address - Street 2:SUITE 220
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-9069
Mailing Address - Country:US
Mailing Address - Phone:770-302-6780
Mailing Address - Fax:678-782-3776
Practice Address - Street 1:80 VININGS DR
Practice Address - Street 2:
Practice Address - City:MCDONOUGH
Practice Address - State:GA
Practice Address - Zip Code:30253-5994
Practice Address - Country:US
Practice Address - Phone:770-302-6780
Practice Address - Fax:678-782-3776
Is Sole Proprietor?:No
Enumeration Date:2016-01-19
Last Update Date:2016-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN195334163W00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA2025I00235Medicare PIN