Provider Demographics
NPI:1205344421
Name:PAYNE, VANESSA ANN
Entity type:Individual
Prefix:
First Name:VANESSA
Middle Name:ANN
Last Name:PAYNE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7348 HILLMONT DR
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94605-2928
Mailing Address - Country:US
Mailing Address - Phone:786-506-2181
Mailing Address - Fax:
Practice Address - Street 1:7348 HILLMONT DR
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94605-2928
Practice Address - Country:US
Practice Address - Phone:786-506-2181
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-22
Last Update Date:2018-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLF236875657910172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver