Healthcare Provider Details

I. General information

NPI: 1639344294
Provider Name (Legal Business Name): KRISTEN JOY PAYNE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2008
Last Update Date: 04/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 9TH ST SUITE B
MODESTO CA
95354-3428
US

IV. Provider business mailing address

901 CALIFORNIA AVE #5
MODESTO CA
95351-2582
US

V. Phone/Fax

Practice location:
  • Phone: 209-341-1824
  • Fax: 209-523-1296
Mailing address:
  • Phone: 209-575-1790
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: