Provider Demographics
NPI:1205505724
Name:PAYNE, RUSSELL BERRY (APRN)
Entity type:Individual
Prefix:
First Name:RUSSELL
Middle Name:BERRY
Last Name:PAYNE
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 TRENT RD
Mailing Address - Street 2:
Mailing Address - City:HOOKSETT
Mailing Address - State:NH
Mailing Address - Zip Code:03106-1709
Mailing Address - Country:US
Mailing Address - Phone:603-210-1703
Mailing Address - Fax:603-210-1703
Practice Address - Street 1:88 MCGREGOR ST STE 105
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:NH
Practice Address - Zip Code:03102-3732
Practice Address - Country:US
Practice Address - Phone:603-663-6252
Practice Address - Fax:603-663-6257
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-08
Last Update Date:2023-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH065287-23363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health