Provider Demographics
NPI:1336930148
Name:PAYNE, TRISTANE KATHLEEN (NP)
Entity type:Individual
Prefix:
First Name:TRISTANE
Middle Name:KATHLEEN
Last Name:PAYNE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1217 KEARNEY ST STE 2
Mailing Address - Street 2:
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060-3571
Mailing Address - Country:US
Mailing Address - Phone:810-689-3886
Mailing Address - Fax:
Practice Address - Street 1:1217 KEARNEY ST STE 2
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-3571
Practice Address - Country:US
Practice Address - Phone:810-990-8302
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-13
Last Update Date:2025-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704327381363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner