Healthcare Provider Details

I. General information

NPI: 1205344421
Provider Name (Legal Business Name): VANESSA ANN PAYNE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/22/2018
Last Update Date: 01/22/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7348 HILLMONT DR
OAKLAND CA
94605-2928
US

IV. Provider business mailing address

7348 HILLMONT DR
OAKLAND CA
94605-2928
US

V. Phone/Fax

Practice location:
  • Phone: 786-506-2181
  • Fax:
Mailing address:
  • Phone: 786-506-2181
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License NumberF236875657910
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: