MEDICARE: MRS. LISA ANN PAYNE OTR

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	172V00000X	Community Health Worker	000489	MO

General Provider Information

NPI Number	:	1851558423
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. LISA ANN PAYNE OTR

Provider Business Mailing Address
First Line	:	738 BLAIRBETH DR
Second Line	:
City	:	WELDON SPRING
State	:	MO
Zip	:	63304-7580
Country	:	US
Telephone Number	:	314-776-1300
Fax Number	:

Provider Business Practice Location Address
First Line	:	5030 MCREE AVE
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63110-2046
Country	:	US
Telephone Number	:	314-776-1300
Fax Number	:

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

Provider Enumeration Date	:	05/20/2008
Last Update Date	:	05/20/2008

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