Provider Demographics
NPI:1336545391
Name:PAYNE, LORI
Entity type:Individual
Prefix:
First Name:LORI
Middle Name:
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 1:5551 WINGHAVEN BLVD
Mailing Address - Street 2:SUITE 240
Mailing Address - City:O FALLON
Mailing Address - State:MO
Mailing Address - Zip Code:63368-3617
Mailing Address - Country:US
Mailing Address - Phone:636-561-5561
Mailing Address - Fax:636-561-5557
Practice Address - Street 1:5551 WINGHAVEN BLVD
Practice Address - Street 2:SUITE 240
Practice Address - City:O FALLON
Practice Address - State:MO
Practice Address - Zip Code:63368-3617
Practice Address - Country:US
Practice Address - Phone:636-561-5561
Practice Address - Fax:636-561-5557
Is Sole Proprietor?:No
Enumeration Date:2014-11-18
Last Update Date:2014-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010022198363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics