Healthcare Provider Details

I. General information

NPI: 1104378587
Provider Name (Legal Business Name): AMANDA EVELYN PAYNE ATC/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/01/2016
Last Update Date: 11/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19600 E 39TH ST S
INDEPENDENCE MO
64057-2301
US

IV. Provider business mailing address

3323 N PERRIN RD
INDEPENDENCE MO
64058-2276
US

V. Phone/Fax

Practice location:
  • Phone: 816-698-8860
  • Fax:
Mailing address:
  • Phone: 816-808-4934
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number20100028670
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: