Basic Information
| Provider Information | |||||||||
| NPI: | 1316258437 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STEWART-JAYNES | ||||||||
| FirstName: | MARISSA | ||||||||
| MiddleName: | LAYNE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | STEWART | ||||||||
| OtherFirstName: | MARISSA | ||||||||
| OtherMiddleName: | L | ||||||||
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| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2200 JEFFERSON AVE FL 5 | ||||||||
| Address2: | |||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436047102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192512032 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 6321 KENTUCKY DAM RD | ||||||||
| Address2: | |||||||||
| City: | PADUCAH | ||||||||
| State: | KY | ||||||||
| PostalCode: | 420039471 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2708988415 | ||||||||
| FaxNumber: | 2708984753 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2010 | ||||||||
| LastUpdateDate: | 10/27/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/27/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 45314 | KY | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 7100176770 | 05 | KY | MEDICAID |