MEDICARE: TYRA NICOLE PAYNE

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	106S00000X	Behavior Technician	RBT-23-317073	TN

General Provider Information

NPI Number	:	1699572164
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TYRA NICOLE PAYNE

Provider Business Mailing Address
First Line	:	1052 S COOPER ST APT 2
Second Line	:
City	:	MEMPHIS
State	:	TN
Zip	:	38104-5649
Country	:	US
Telephone Number	:	901-325-9397
Fax Number	:

Provider Business Practice Location Address
First Line	:	1052 S COOPER ST APT 2
Second Line	:
City	:	MEMPHIS
State	:	TN
Zip	:	38104-5649
Country	:	US
Telephone Number	:	901-325-9397
Fax Number	:

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

Provider Enumeration Date	:	03/03/2025
Last Update Date	:	03/03/2025

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Directions to “ TYRA NICOLE PAYNE ” Practice Location

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