Provider Demographics
NPI:1881220648
Name:PAYNE, MARINA ELYSE (FNP-C)
Entity Type:Individual
Prefix:
First Name:MARINA
Middle Name:ELYSE
Last Name:PAYNE
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3952 OSAGE ST
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80211-2663
Mailing Address - Country:US
Mailing Address - Phone:832-628-7715
Mailing Address - Fax:
Practice Address - Street 1:777 BANNOCK ST
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80204-4507
Practice Address - Country:US
Practice Address - Phone:832-628-7715
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-12
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1618672163W00000X
CO0996021363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1618672OtherCOLORADO DORA