Provider Demographics
NPI:1093206674
Name:TRAVIS, LUCILLE (NP)
Entity Type:Individual
Prefix:MRS
First Name:LUCILLE
Middle Name:
Last Name:TRAVIS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4095 ATLANTA HWY
Mailing Address - Street 2:
Mailing Address - City:HIRAM
Mailing Address - State:GA
Mailing Address - Zip Code:30141-1854
Mailing Address - Country:US
Mailing Address - Phone:404-488-9521
Mailing Address - Fax:404-836-8030
Practice Address - Street 1:4095 ATLANTA HWY
Practice Address - Street 2:
Practice Address - City:HIRAM
Practice Address - State:GA
Practice Address - Zip Code:30141-1854
Practice Address - Country:US
Practice Address - Phone:404-488-9521
Practice Address - Fax:404-836-8030
Is Sole Proprietor?:No
Enumeration Date:2018-05-19
Last Update Date:2024-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN195568363LG0600X, 363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology