Provider Demographics
NPI:1003833989
Name:PAYNE, ELLEN K (MA, ATC, CSCS)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:K
Last Name:PAYNE
Suffix:
Gender:F
Credentials:MA, ATC, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 247
Mailing Address - Street 2:
Mailing Address - City:CUPERTINO
Mailing Address - State:CA
Mailing Address - Zip Code:95015-0247
Mailing Address - Country:US
Mailing Address - Phone:408-348-7448
Mailing Address - Fax:
Practice Address - Street 1:302 PORTOLA RD
Practice Address - Street 2:
Practice Address - City:PORTOLA VALLEY
Practice Address - State:CA
Practice Address - Zip Code:94028-7851
Practice Address - Country:US
Practice Address - Phone:650-851-6128
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer