Provider Demographics
NPI:1023379617
Name:TRAVIS, EDWARD III (STNA)
Entity Type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:
Last Name:TRAVIS
Suffix:III
Gender:M
Credentials:STNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3614 W 127TH ST
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44111-4501
Mailing Address - Country:US
Mailing Address - Phone:216-215-7570
Mailing Address - Fax:
Practice Address - Street 1:3614 W 127TH ST
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44111-4501
Practice Address - Country:US
Practice Address - Phone:216-215-7570
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-31
Last Update Date:2012-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH375235471295376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide