Provider Demographics
NPI:1356686992
Name:PAYNE, KIMBERLIE ANN (COTA)
Entity Type:Individual
Prefix:
First Name:KIMBERLIE
Middle Name:ANN
Last Name:PAYNE
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13209 FOUNTAIN DR
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:CA
Mailing Address - Zip Code:95386-8858
Mailing Address - Country:US
Mailing Address - Phone:808-937-3172
Mailing Address - Fax:
Practice Address - Street 1:13209 FOUNTAIN DR
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:CA
Practice Address - Zip Code:95386-8858
Practice Address - Country:US
Practice Address - Phone:808-937-3172
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-08
Last Update Date:2012-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOC60114073224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant