Healthcare Provider Details

I. General information

NPI: 1871592469
Provider Name (Legal Business Name): RENEE PAYNE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2005
Last Update Date: 11/10/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8500 EXECUTIVE PARK AVE SUITE 200
FAIRFAX VA
22031-2225
US

IV. Provider business mailing address

8500 EXECUTIVE PARK AVE SUITE 200
FAIRFAX VA
22031-2225
US

V. Phone/Fax

Practice location:
  • Phone: 703-698-5220
  • Fax: 703-573-2351
Mailing address:
  • Phone: 703-698-5220
  • Fax: 703-573-2351

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number0101055149
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: