Provider Demographics
NPI:1932838398
Name:PAYNE, NICOLE D
Entity Type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:D
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 1:3393 W 21ST PL
Mailing Address - Street 2:
Mailing Address - City:YUMA
Mailing Address - State:AZ
Mailing Address - Zip Code:85364-5940
Mailing Address - Country:US
Mailing Address - Phone:928-750-3022
Mailing Address - Fax:
Practice Address - Street 1:115 N. SOMERTON AVE
Practice Address - Street 2:
Practice Address - City:SOMERTON
Practice Address - State:AZ
Practice Address - Zip Code:85350
Practice Address - Country:US
Practice Address - Phone:928-627-8806
Practice Address - Fax:928-627-1126
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-09
Last Update Date:2022-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZH008905124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist