Healthcare Provider Details

I. General information

NPI: 1700986239
Provider Name (Legal Business Name): EDITH A PAYNE CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/24/2006
Last Update Date: 04/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 NE MULBERRY ST STE 202 SJS MEDICAL MANAGEMENT
LEES SUMMIT MO
64086-4533
US

IV. Provider business mailing address

250 NE MULBERRY ST STE 202 SJS MEDICAL MANAGEMENT
LEES SUMMIT MO
64086-4533
US

V. Phone/Fax

Practice location:
  • Phone: 816-389-4130
  • Fax: 816-389-4140
Mailing address:
  • Phone: 816-389-4130
  • Fax: 816-389-4140

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number056282
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: