Provider Demographics
NPI:1295088144
Name:PAYNE-BLAKE, ALICE M
Entity type:Individual
Prefix:MRS
First Name:ALICE
Middle Name:M
Last Name:PAYNE-BLAKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ALICE
Other - Middle Name:M
Other - Last Name:PAYNE-BLAKE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DIETITIC TECHNICIAN
Mailing Address - Street 1:540 NE 179TH DR
Mailing Address - Street 2:
Mailing Address - City:NORTH MIAMI BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33162-1922
Mailing Address - Country:US
Mailing Address - Phone:305-650-9024
Mailing Address - Fax:
Practice Address - Street 1:540 NE 179TH DR
Practice Address - Street 2:MIAMI
Practice Address - City:NORTH MIAMI BEACH
Practice Address - State:FL
Practice Address - Zip Code:33162-1922
Practice Address - Country:US
Practice Address - Phone:305-650-9024
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-16
Last Update Date:2012-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL718051136A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes136A00000XDietary & Nutritional Service ProvidersDietetic Technician, Registered