MEDICARE: ASHLEY MARIE PAYNE RN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	R190427-3	MN

General Provider Information

NPI Number	:	1497051361
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ASHLEY MARIE PAYNE RN

Provider Business Mailing Address
First Line	:	910 FOREST CITY BLVD NW
Second Line	:
City	:	MAPLE LAKE
State	:	MN
Zip	:	55358-3542
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	910 FOREST CITY BLVD NW
Second Line	:
City	:	MAPLE LAKE
State	:	MN
Zip	:	55358-3542
Country	:	US
Telephone Number	:	612-695-8614
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/09/2011
Last Update Date	:	02/09/2011

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