Provider Demographics
NPI:1164900833
Name:PAYTON, CHANNETTA NIKOLE
Entity Type:Individual
Prefix:
First Name:CHANNETTA
Middle Name:NIKOLE
Last Name:PAYTON
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 1:3282 BERKSHIRE RD
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND HTS
Mailing Address - State:OH
Mailing Address - Zip Code:44118-2525
Mailing Address - Country:US
Mailing Address - Phone:216-632-0500
Mailing Address - Fax:
Practice Address - Street 1:3282 BERKSHIRE RD
Practice Address - Street 2:
Practice Address - City:CLEVELAND HTS
Practice Address - State:OH
Practice Address - Zip Code:44118-2525
Practice Address - Country:US
Practice Address - Phone:216-632-0500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-03
Last Update Date:2018-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist