Provider Demographics
NPI:1851558423
Name:PAYNE, LISA ANN (OTR)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:ANN
Last Name:PAYNE
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:738 BLAIRBETH DR
Mailing Address - Street 2:
Mailing Address - City:WELDON SPRING
Mailing Address - State:MO
Mailing Address - Zip Code:63304-7580
Mailing Address - Country:US
Mailing Address - Phone:314-776-1300
Mailing Address - Fax:
Practice Address - Street 1:5030 MCREE AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-2046
Practice Address - Country:US
Practice Address - Phone:314-776-1300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-20
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO000489172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker