Provider Demographics
NPI:1336877570
Name:PAYNE, KANISHA SADE
Entity type:Individual
Prefix:
First Name:KANISHA
Middle Name:SADE
Last Name:PAYNE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KANISHA
Other - Middle Name:SADE
Other - Last Name:ECKART
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:12251 RAMBLING ROSE WAY
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:AR
Mailing Address - Zip Code:72730-8819
Mailing Address - Country:US
Mailing Address - Phone:479-599-9576
Mailing Address - Fax:
Practice Address - Street 1:3155 N COLLEGE AVE STE 108
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-3500
Practice Address - Country:US
Practice Address - Phone:479-957-9121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-14
Last Update Date:2022-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician