Provider Demographics
NPI:1487025300
Name:PAYNE, MICHELLE LAUREN
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:LAUREN
Last Name:PAYNE
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:MICHELLE
Other - Middle Name:
Other - Last Name:TILLMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:504 BROOKWOOD BLVD
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35209-6802
Mailing Address - Country:US
Mailing Address - Phone:205-871-9661
Mailing Address - Fax:205-870-1621
Practice Address - Street 1:504 BROOKWOOD BLVD
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35209-6802
Practice Address - Country:US
Practice Address - Phone:205-871-9661
Practice Address - Fax:205-870-1621
Is Sole Proprietor?:No
Enumeration Date:2015-10-19
Last Update Date:2015-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-131372363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily