Provider Demographics
NPI:1720587009
Name:PAYNE, ASHLEY MICHELLE (PTA)
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:MICHELLE
Last Name:PAYNE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:ASHLEY
Other - Middle Name:MICHELLE
Other - Last Name:RENN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:4440 HETH WASHINGTON RD SW
Mailing Address - Street 2:
Mailing Address - City:CENTRAL
Mailing Address - State:IN
Mailing Address - Zip Code:47110-7826
Mailing Address - Country:US
Mailing Address - Phone:502-645-7359
Mailing Address - Fax:
Practice Address - Street 1:118 MEDICAL DR
Practice Address - Street 2:
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46032-2923
Practice Address - Country:US
Practice Address - Phone:317-573-1037
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-01
Last Update Date:2018-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06005557A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant