Provider Demographics
NPI:1912363797
Name:PAYNE, ABIGAIL ANGELICA (LMP)
Entity Type:Individual
Prefix:
First Name:ABIGAIL
Middle Name:ANGELICA
Last Name:PAYNE
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19013 33RD AVE NE
Mailing Address - Street 2:APT C
Mailing Address - City:LAKE FOREST PARK
Mailing Address - State:WA
Mailing Address - Zip Code:98155-2565
Mailing Address - Country:US
Mailing Address - Phone:206-499-3758
Mailing Address - Fax:
Practice Address - Street 1:3933 STONE WAY N
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98103-8017
Practice Address - Country:US
Practice Address - Phone:206-588-0014
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-08
Last Update Date:2016-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60618384171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor