Provider Demographics
NPI:1376108316
Name:PAYNE, ANNA FORTUNATO (PTA)
Entity Type:Individual
Prefix:
First Name:ANNA
Middle Name:FORTUNATO
Last Name:PAYNE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12669 SHARP LN
Mailing Address - Street 2:
Mailing Address - City:PORT ALLEN
Mailing Address - State:LA
Mailing Address - Zip Code:70767-5427
Mailing Address - Country:US
Mailing Address - Phone:225-939-1350
Mailing Address - Fax:
Practice Address - Street 1:1160 HOSPITAL RD STE 100
Practice Address - Street 2:
Practice Address - City:NEW ROADS
Practice Address - State:LA
Practice Address - Zip Code:70760-2633
Practice Address - Country:US
Practice Address - Phone:225-638-4455
Practice Address - Fax:225-208-6173
Is Sole Proprietor?:No
Enumeration Date:2019-05-06
Last Update Date:2019-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAA4574225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAA4574OtherSTATE LICENSE