Provider Demographics
NPI:1912579087
Name:PAYTON, CHRISTINA GRACE (ATC)
Entity Type:Individual
Prefix:
First Name:CHRISTINA
Middle Name:GRACE
Last Name:PAYTON
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:315 SOUTH GROVE STREET
Mailing Address - Street 2:
Mailing Address - City:CRESTON
Mailing Address - State:IL
Mailing Address - Zip Code:60113
Mailing Address - Country:US
Mailing Address - Phone:815-520-2821
Mailing Address - Fax:
Practice Address - Street 1:315 SOUTH GROVE STREET
Practice Address - Street 2:
Practice Address - City:CRESTON
Practice Address - State:IL
Practice Address - Zip Code:60113
Practice Address - Country:US
Practice Address - Phone:815-520-2821
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-16
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2601002634207PS0010X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PS0010XAllopathic & Osteopathic PhysiciansEmergency MedicineSports Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program