Provider Demographics
NPI:1083705909
Name:PAYNE, THERESA MARIE (NP)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:MARIE
Last Name:PAYNE
Suffix:
Gender:F
Credentials:NP
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 54130
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90054-0130
Mailing Address - Country:US
Mailing Address - Phone:951-687-3200
Mailing Address - Fax:951-687-8923
Practice Address - Street 1:3660 PARK SIERRA DR
Practice Address - Street 2:SUITE 208
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92505-3059
Practice Address - Country:US
Practice Address - Phone:951-687-2800
Practice Address - Fax:951-687-7290
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2012-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP13322363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner