Provider Demographics
NPI:1811972805
Name:PAYNE WAGNER, MELISSA S (PT)
Entity type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:S
Last Name:PAYNE WAGNER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MS
Other - First Name:MELISSA
Other - Middle Name:S
Other - Last Name:PAYNE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:3266 SYCAMORE RD
Mailing Address - Street 2:
Mailing Address - City:DEKALB
Mailing Address - State:IL
Mailing Address - Zip Code:60115-9621
Mailing Address - Country:US
Mailing Address - Phone:815-756-8524
Mailing Address - Fax:815-756-1841
Practice Address - Street 1:3266 SYCAMORE RD
Practice Address - Street 2:
Practice Address - City:DEKALB
Practice Address - State:IL
Practice Address - Zip Code:60115-9621
Practice Address - Country:US
Practice Address - Phone:815-756-8524
Practice Address - Fax:815-756-1841
Is Sole Proprietor?:No
Enumeration Date:2005-12-13
Last Update Date:2017-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070013020225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
650023317OtherRAILROAD MEDICARE
L90916Medicare UPIN