Basic Information
| Provider Information | |||||||||
| NPI: | 1457528986 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PAYNE | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | YLONNE | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 460 MALL BLVD | ||||||||
| Address2: | SUITE B | ||||||||
| City: | SAVANNAH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 314064801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9126445300 | ||||||||
| FaxNumber: | 9126443369 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 DOCTORS DR | ||||||||
| Address2: | SUITE I | ||||||||
| City: | DOUGLAS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 315332210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9123836575 | ||||||||
| FaxNumber: | 9123836476 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/14/2008 | ||||||||
| LastUpdateDate: | 10/03/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | 068269 | GA | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | 208100000X | 35.091613 | OH | N | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | 208100000X | MD60463507 | WA | N | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | P00703245 | 01 | TN | RRMCR | OTHER | 326916 | 01 | WA | STATE L&I | OTHER | 1508994 | 05 | TN | MEDICAID |