Provider Demographics
NPI:1629358759
Name:PAYNE, MICHELLE YVONNE (STNA)
Entity Type:Individual
Prefix:MS
First Name:MICHELLE
Middle Name:YVONNE
Last Name:PAYNE
Suffix:
Gender:F
Credentials:STNA
Other - Prefix:MS
Other - First Name:MICHELLE
Other - Middle Name:YVONNE
Other - Last Name:BEDEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:STNA
Mailing Address - Street 1:16408 MYRTLE AVE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44128-3830
Mailing Address - Country:US
Mailing Address - Phone:216-475-5781
Mailing Address - Fax:
Practice Address - Street 1:16408 MYRTLE AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44128-3830
Practice Address - Country:US
Practice Address - Phone:216-513-4920
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-21
Last Update Date:2011-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH401104380610172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker