Provider Demographics
NPI:1164716007
Name:PAYNE, MELISSA ANN
Entity Type:Individual
Prefix:MS
First Name:MELISSA
Middle Name:ANN
Last Name:PAYNE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:331 CAJON ST
Mailing Address - Street 2:APT B
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373-5964
Mailing Address - Country:US
Mailing Address - Phone:909-496-2978
Mailing Address - Fax:
Practice Address - Street 1:123 N E ST
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92401-1921
Practice Address - Country:US
Practice Address - Phone:909-884-6677
Practice Address - Fax:909-884-9496
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-08
Last Update Date:2011-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA0561780225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist