Provider Demographics
NPI:1376200188
Name:PAYNE, ANISHKA
Entity Type:Individual
Prefix:
First Name:ANISHKA
Middle Name:
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 1:6211 NOTTINGHAM AVE FL 1
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63109-3144
Mailing Address - Country:US
Mailing Address - Phone:314-366-2490
Mailing Address - Fax:
Practice Address - Street 1:6211 NOTTINGHAM AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63109-3144
Practice Address - Country:US
Practice Address - Phone:314-366-2490
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-29
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist