Provider Demographics
NPI:1235785924
Name:PAYNE, MELBA G
Entity Type:Individual
Prefix:
First Name:MELBA
Middle Name:G
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 1:4171 CHAMPAGNE LN
Mailing Address - Street 2:
Mailing Address - City:SUMTER
Mailing Address - State:SC
Mailing Address - Zip Code:29153-7795
Mailing Address - Country:US
Mailing Address - Phone:803-469-4641
Mailing Address - Fax:
Practice Address - Street 1:4171 CHAMPAGNE LN
Practice Address - Street 2:
Practice Address - City:SUMTER
Practice Address - State:SC
Practice Address - Zip Code:29153-7795
Practice Address - Country:US
Practice Address - Phone:803-469-4641
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-17
Last Update Date:2019-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC50032164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse