Provider Demographics
NPI:1558020685
Name:PAYETTE, PAMELA TINA (BSN, RN)
Entity Type:Individual
Prefix:MRS
First Name:PAMELA
Middle Name:TINA
Last Name:PAYETTE
Suffix:
Gender:F
Credentials:BSN, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1380 DUBLIN RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43215-1025
Mailing Address - Country:US
Mailing Address - Phone:740-488-7117
Mailing Address - Fax:
Practice Address - Street 1:1380 DUBLIN RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43215-1025
Practice Address - Country:US
Practice Address - Phone:614-488-7117
Practice Address - Fax:614-488-7118
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-16
Last Update Date:2021-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH387015163WA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WA0400XNursing Service ProvidersRegistered NurseAddiction (Substance Use Disorder)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH263260689Medicaid