Provider Demographics
NPI:1538590153
Name:PAYNE, KUWANANH
Entity type:Individual
Prefix:
First Name:KUWANANH
Middle Name:
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 1:6237 MERRILL RD
Mailing Address - Street 2:6237 MERILL ROAD
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32277-3512
Mailing Address - Country:US
Mailing Address - Phone:904-744-2111
Mailing Address - Fax:904-493-0109
Practice Address - Street 1:6237 MERRILL RD
Practice Address - Street 2:6237 MERRILL ROAD
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32277-3512
Practice Address - Country:US
Practice Address - Phone:904-744-2111
Practice Address - Fax:904-493-0109
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-07
Last Update Date:2013-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDH10223124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist