Provider Demographics
NPI:1790936870
Name:PAYNE, TESSA L (CRNP)
Entity Type:Individual
Prefix:
First Name:TESSA
Middle Name:L
Last Name:PAYNE
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:TESSA
Other - Middle Name:L
Other - Last Name:GROVES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNP
Mailing Address - Street 1:2401 W BELVEDERE AVE
Mailing Address - Street 2:CREDENTIALING
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21215-5216
Mailing Address - Country:US
Mailing Address - Phone:410-601-5523
Mailing Address - Fax:410-601-8946
Practice Address - Street 1:2401 W BELVEDERE AVE
Practice Address - Street 2:PEDIATRIC ICU
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21215-5216
Practice Address - Country:US
Practice Address - Phone:410-601-9193
Practice Address - Fax:410-601-4962
Is Sole Proprietor?:No
Enumeration Date:2008-10-07
Last Update Date:2010-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR147475363LP0222X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0222XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics, Critical Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDKN62Medicare PIN