Provider Demographics
NPI:1770041535
Name:PAYNE, DEMONA
Entity Type:Individual
Prefix:
First Name:DEMONA
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 1:3952 TRIPLE CROWN DR
Mailing Address - Street 2:
Mailing Address - City:FLORISSANT
Mailing Address - State:MO
Mailing Address - Zip Code:63034-3404
Mailing Address - Country:US
Mailing Address - Phone:314-477-1091
Mailing Address - Fax:
Practice Address - Street 1:3952 TRIPLE CROWN DR
Practice Address - Street 2:
Practice Address - City:FLORISSANT
Practice Address - State:MO
Practice Address - Zip Code:63034-3404
Practice Address - Country:US
Practice Address - Phone:314-477-1091
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-11
Last Update Date:2019-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health