Provider Demographics
NPI:1225506934
Name:KENNEY, TRAVIS CHRISTOPHER
Entity Type:Individual
Prefix:
First Name:TRAVIS
Middle Name:CHRISTOPHER
Last Name:KENNEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4805 LOVELL AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76107-5326
Mailing Address - Country:US
Mailing Address - Phone:817-714-5219
Mailing Address - Fax:
Practice Address - Street 1:4544 S LAMAR BLVD
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78745-1500
Practice Address - Country:US
Practice Address - Phone:512-433-6333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-12
Last Update Date:2018-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP138484363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily