Provider Demographics
NPI:1104378587
Name:PAYNE, AMANDA EVELYN (ATC/L)
Entity Type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:EVELYN
Last Name:PAYNE
Suffix:
Gender:F
Credentials:ATC/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3323 N PERRIN RD
Mailing Address - Street 2:
Mailing Address - City:INDEPENDENCE
Mailing Address - State:MO
Mailing Address - Zip Code:64058-2276
Mailing Address - Country:US
Mailing Address - Phone:816-808-4934
Mailing Address - Fax:
Practice Address - Street 1:19600 E 39TH ST S
Practice Address - Street 2:
Practice Address - City:INDEPENDENCE
Practice Address - State:MO
Practice Address - Zip Code:64057-2301
Practice Address - Country:US
Practice Address - Phone:816-698-8860
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-01
Last Update Date:2016-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO201000286702255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer