Provider Demographics
NPI:1447370838
Name:PAYNE, SUSAN MELANSON
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:MELANSON
Last Name:PAYNE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:ANN
Other - Last Name:MELANSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:55 FOX RD
Mailing Address - Street 2:APT 921
Mailing Address - City:WALTHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02451-0245
Mailing Address - Country:US
Mailing Address - Phone:520-921-0356
Mailing Address - Fax:
Practice Address - Street 1:85 1ST AVE
Practice Address - Street 2:
Practice Address - City:WALTHAM
Practice Address - State:MA
Practice Address - Zip Code:02451-1105
Practice Address - Country:US
Practice Address - Phone:781-647-7246
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA86244367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered