Provider Demographics
NPI:1356822555
Name:PAYNE, BETTY JANE (LPN)
Entity Type:Individual
Prefix:MRS
First Name:BETTY
Middle Name:JANE
Last Name:PAYNE
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1203 MARKET AVE
Mailing Address - Street 2:
Mailing Address - City:JOHNSTON CITY
Mailing Address - State:IL
Mailing Address - Zip Code:62951-1842
Mailing Address - Country:US
Mailing Address - Phone:618-525-5775
Mailing Address - Fax:
Practice Address - Street 1:1203 MARKET AVE
Practice Address - Street 2:
Practice Address - City:JOHNSTON CITY
Practice Address - State:IL
Practice Address - Zip Code:62951-1842
Practice Address - Country:US
Practice Address - Phone:618-525-5775
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-24
Last Update Date:2018-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL043120069164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse